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Please print or tvoe. (Form deslanad for use on AlitA 112-nitchi tvnAwfitar I P— A,W v w uJ MAP hk 1)nrn-nn'lo <br />tFrk t orm tiluu-ZZ (liav, 3-Ub) Frevious e(Jilions are obsolete. I DESIGNATED fiA-CIEITY TO DEr-TTWATION STATE (IF ReMVIRED) <br />q. UNIFORW K42ARDOUS <br />I Generator 1D Number <br />2. Page i of <br />C nergency Respor" Phone Manifest Tracking Number <br />WASTE MANIFEST <br />013809602 JJK <br />z�. GenorAoes Name and MallmqAddvess: Gonarators Site Address (11 dinront t1w <br />t, <br />Generator's Phone: Z; 7 014 <br />—Tmn*,o110rl <br />7, Company Nants U.S. EPA ID Number <br />1; 1, F, Y r 1.4 V1, [11 5,F: N 7, 5 7 Y <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8, Designated Facility Name and Silo Address U.S. EPA lD Number <br />'v't,100UA <br />5;S75 'SOOTH k ml'.�,C-N j <br />LOS ANGELES CA 90058 <br />Facility's Phcne: ('31 2 31.2 7 "7-1 s 6 o <br />ga, <br />9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WIROL <br />13. Waste Codes <br />No. <br />Type <br />bT'h08T'vPRCv11A HAaMOUPS ,SO ID PAINT CHIPS) <br />0 <br />D to <br />(0 0 <br />P <br />2, <br />LU <br />3. <br />14, Special Handling instructions and Additional information ----------- <br />EMERGE NCYO-61NIACDT CHEFATIREC 1-800-424-93' DO MAERGR# 991 ;17 ` POFILE # -R1 - APIO 4 70 FAINT <br />R 2 <br />(UN ; * PON A110197455 APPROPRIATE KIRSONAL FROTECTIMEQUIPM v- 71, <br />15. GENMTORStOFFStOR'SCERTIFICATION: I'hirft declare thafthe contents of this consignment are fully 004=nIoly dowilood aLovaby the proper 440V nsme, and are classified, pa4kard'-- <br />marked and labelaNplacarkA, and are in alf"ISpods In Proper ourdtloa ler banspod aocorft to Opplr tbte International and national governmental regulations. 9 export shipment and I am livirPrimaty <br />Exporlar. I certify that the contents of this consignment owilom to the terms of the attached EPA Admowledgment of Conseh(; <br />I coddy, that the waste minimization Statement Identified In 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (9 1 am a small quantity generator) Is true. <br />— <br />PrintedirTyped Name Sigrratur Wain Day Year <br />lilim VMS <br />L❑J import to U.S.a Export from U.S. Port of entrylexit <br />Trajispodar, signature (for. exports only): Date ImAng VS., <br />17.TrarisporturAcluiowledgment of Recelpt of Materials <br />TZraispo r1punted/T dN Signature H Month Day Year <br />YP22 A De <br />Z <br />< <br />rarisporInr 2 PantuXTypad N&o Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ElTypa R E't FEW IV E ff Partial Rejection El Full Rejection <br />Manifest Reference Number <br />I— <br />18b. Afternate'Facility (or Generator)U.S. EPA ID Number <br />IJ 2017 <br />U<- <br />Facility's Phone: <br />NHFNTAI HPAIIIII <br />18c. Signature of Alternate Facility (or Generator)PERMIT/SERKES-­ <br />Monih ay Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, afid.4acycling systems) <br />0 <br />1. <br />Z <br />2G Designated Facility Owner or Operator. Certification -of receipt of hazardous by the man fest exceptas, noted "v /Al <br />.."n'Item <br />PramailTyped Name igasaftlre Mdnth Day Year <br />tFrk t orm tiluu-ZZ (liav, 3-Ub) Frevious e(Jilions are obsolete. I DESIGNATED fiA-CIEITY TO DEr-TTWATION STATE (IF ReMVIRED) <br />