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SSL SK SHIP <br /> 0 0 6 0 9 9 6 0 2 S K 5 <br /> Please print or type,(Form designed for use on elite(12-p4ch)typewriter.) Form Approved.OMB No.2050-003g <br /> UNIFORM HAZARDOUS J1,G8aerq11rriDNvrnber <br /> . f[ —nfte ffgo Manifest Tracking Number <br /> WASTEMANWEST OJ-602 a [V <br /> 5.Generator's Name and Mailing Address � g Generators Site Address(if different than mailing address) <br /> t W.. 0L R <br /> q - qO 3 e-1 <br /> SYSTM INS u.s.EPA IDNumber TX RM08 1205 <br /> 7Trens'` 2fr" NBiiie U.S.EPA ID Number <br /> SERVICES INC - - MAD039322250 <br /> 'Lr5 <br /> �d tityY fame a 3'�sae Aclase sHn Rs I L INT LLQ �s.LPA ID Number <br /> 1737 EAST DENNI STREET <br /> WILMINGTONCA 90744R <br /> [ndudi ttd Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11'.Total 12.Unit <br /> 13.Waste Codes <br /> No. Type Quanf4 Wt.IVol. <br /> N q ' <br /> b <br /> § <br /> tmoansand AddiUonallnformahon TSD.-WI CSG.- <br /> (SK TFD <br /> y!^{�#.� �}�q�y%� y�f y RETAIN <br /> LICENSED <br /> �} �F�y CARRIERS <br /> p�p�}g q-� {��+ �q �r^p+' +yq �/ �^j`'y <br /> ... 8'LY'i R71Bffi�s€��1Yd 8F� L.4�e #�a�$ L x'�S.F&7 i�r�iieR.Ri'S Piw7 6�lGa�a6'S t•:/� <br /> n <br /> IS CERTtF1CATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> e X _ CaU tali arod are in all respects fn proper condition for transport according to applicable intemational and national govemmental regulations.If export shipment and I am the Primary <br /> Wilt contents of this consignment conform fe the terms of the attached EPAAcknOWl unt of Consent. <br /> t t(ts h iafwn statement idem f ed in 40 CFR 262.27[a}(if I am a large quality genera or(b)(if I am a r is true. <br /> aAe Signatu Y, n#ri" Day Year. <br /> E <br /> i~ r r ❑Export from U.S. Part of en !exit <br /> � 's^' f�'��tRr ef1�otafiY} Date leavi U.S.: <br /> ti s ftteti9ment of Receipt ofMatoriats <br /> 4 i+{at Signature Month Day Year <br /> F 4 jJ <br /> w .. - <br /> �s gid�iem6, Signature Month Day Year <br /> 1�brs`crep�cy <br /> iSa'biscrepahcy tnda.IfQn apaceQuarttAY ❑Type ❑e Residue ❑PartiaI ❑Full Rejection <br /> ❑ ' iRe'ecfivn <br /> Manifest ReferenceNumbor. <br /> 18b.Ri[ertite Far�iity(ar Generator} U.S.EPA ID Number <br /> L3 <br /> acuity's Phone: <br /> t8e.Signature of Alternate Facility(or Gunerator) Month Day Year <br /> I¢ <br /> x <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,oodes for hazardous waste treatment,disposal,and recycling systems) <br /> is I. 2 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 � <br /> Pnntedlfyped Name Signature Month Day Year <br /> EP. %8,79N <br /> -Yy �P v. evious edition ,s are obsolete. DE$I ED ClL.TYTO DESTINATION STATE(IF REQUIRED) <br />