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Please print or We; (Form designed for use on e1ite'Ip. tc writer.). Form roved - .OMB No. 2050-0039 n g L UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. �lantf s; Trackin Number WASTE MANIFEST } M LLJ 25 JJK 5. Generator's Name and Mailing Address. Generator's Site Address (if different than mailing address) CAL rp4a�ukmz SHOP 'Z 2. . 5 8T' _ ?� F A C7 Generators'Phone, �x"s 6. Transporter 1 Cqmpany Name U.S, EPA ID Number, iCU € ARS'-'§IAt`;' 3. 7. Transporter, 2 Company Name U.S. EPA ID Number 8. Desj nafed F slit Nart{a ar�d Sde Address v't s 36 Et E.l` ` U.S-EPA ID Number 4 6�F m :x a i C F"f Iib: .:k`'a> CA Facility's Phone: � 171 drum size: '. s ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 Total 12 Unik Generator's/Offeror's Pn' tof y ed Name Sign atur Month Day Year HM ,and Pack+ng Group (If any)) ;,,,__,,�, , . 13. Waste Colles �Transpoder 1 P '6te yped Name Signature f r Montes Days e " DESIGNATED FACILITY TO GENERATOR n g L 0 .: -_...-.�........m. LLJ 'Z 2. C7 3. 4 14. Special Handlinstructions and Additional Information E u � 171 drum size: '. s 15; GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according, to applicable international and national governmental regulations. If export shipment and I am the Primary. Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent: I certify that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/Offeror's Pn' tof y ed Name Sign atur Month Day Year J z 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: LLI 17. Transporter Ackrtoybledgment of Receipt of Materials a �Transpoder 1 P '6te yped Name Signature f r Montes Days e aspofter2 Printed/Typed Name Signa6re Month Day Year t- 18. Discrepancy 18a. Discrepancy Indication Space E Quantity ❑ Type yP ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number U LL Facitity's Phone: Uj Q 18c. Signature ofAlternate Facility (or Generator) Month Day Year Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) Uj ® 1 2• 3 4, 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Nam Signature Month Day Year 1/0 t FPA Pnrm R7nn-97 /Rov Z_nGl " DESIGNATED FACILITY TO GENERATOR