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ATTACHMENT A <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.DMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Proi 4.ManYlest Tra iriq Number <br /> T H3 <br /> WASTEMANIFEST (' i i$�-�,��� t,}� � � ��_ �� v F L E <br /> 5.Generators Name and Mailing Address Generators Site Address{if different than mailing address) <br /> hisrAwa tau Sd ind (J lrkA (Skrin Kii <br /> 17M llams St <br /> KIWtt9i Cit 95137 <br /> Generstoes Phone: 2.99- .()9w <br /> Transporter 1 Company Name U.S.EPA ID Number <br /> klwmd Chw"Tri SPW kr. CAFW00070540 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> PO am M'H" I Mies S Benj` NVT&WO" <br /> Beii NV <br /> Facility's Phone: 7n 2203 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11 Total 12.Unit <br /> HM and Panning Group(if any)) 13.Waste Codes <br /> No Type Quantity Wt.Nol. <br /> o x <br /> INA=?,Hsawdaus w"e.kffl d,ma s. {Pttim Siver Lai � P l7�+iE c,41� <br /> a <br /> Sakri 9.PGa " t <br /> w <br /> z 2. <br /> w <br /> C7 , <br /> 3. <br /> i .. <br /> 14.Special Handling Instructions and Addtiionai Information pmod <br /> f+�rrh�btr �� ��t: i:rt t37 7B+ <br /> s)iEF40t 171, M 37750-271 MAi r r <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fui and accurately described above by the proper shipping name,and are classified.packaged. <br /> marked and Iabe.edlplacarded,and are in all respects in proper condition for transport according to applicable mtemational and national govemmentat regulations.N export shipment and lam the Primary <br /> Exporter,f certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> nerator ro s Pfintei Name Signature y <br /> � 16.International.Shipments <br /> ❑Import to U.S. ❑Export from U.S. Part of entrylexit: <br /> Z <br /> Transporter si nature for exports only): <br /> Date leaving U.S.: <br /> 17.Transporter Admowledgnent of Receipt of Mai <br /> LU <br /> Transporter 1 Pon yped�N}ame <br /> CL <br /> Q Transporter 2 Printedryped Name <br /> Month M rear <br /> 18.Discrepancy <br /> '.8a.Discrepancy Indicator.Space <br /> QuerlRy ❑Type ❑Residue ❑Partial Rejection Eli Re,ectior <br /> Manifest Refererkce Number. <br /> F "8b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> 0 <br /> a <br /> w Fadi' s Phone: <br /> w 18c.Signature ofA@emate Facility(or Generator( Month Day Year <br /> a <br /> Z <br /> 15.Hazardous Waste Report Management Method Codes(i.e.,Codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3 4 <br /> 20.Designated Facility Owner or Operator.Ced dcglipn of reoeiat of hazardous materials covered by the manifest except as rioted in Item 1 Ba <br /> Printedrryped N (( Signature Montt. Day Year <br /> EPA Farm 8700.22{Rei 3-05) Previous editlons are obsc late. DESIGNATED FACILITY TO GENERATOR <br />