|
.Print or type.
<br /> UVIFORM HAZARD,9&S 1.GeneraforlD Number Form Approved.OMB No.2050.0639
<br /> Z.Page t of 3.Emergency Response Phone d.Manifesf Tracking Number
<br /> WASTE MANIFE�`�'
<br /> n t,�LEr4 t)3 � 1E-3?1-.5747 � JJ
<br /> 5.Generator's Name and Mailing Address ,,
<br /> ATLnPT IC AVJ tTt0,kl' Generators Site Address(if different than mailing address}
<br /> ,
<br /> 6364 S, UNOB'ERGti gr
<br /> `,JTOGi,TON,CA 932,06
<br /> Generator's Phonpr,
<br /> 6.Transporter 1 Company Name
<br /> tik1C3 Rfl IRiblF,it}TialR'vffe il'1 ..,-' U.S,EPAIDNumber
<br /> 7.Transporter 2 Company NameAydf
<br /> r
<br /> U.S.EPA ID Number
<br /> 8.Designated Facility abie'and Otte Address - r
<br /> PACIFIC RCS01IRa;FR(- OVE y U.S.EPA IDNumber
<br /> w 31;0 eA T Pico ISum
<br /> L62
<br /> (J �tttit^ELES,CA 9C a '
<br /> Facility's Phone6W-499-71.4--55
<br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,
<br /> HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit
<br /> No. Type Quantity Wt.Nol. 13.Waste Codes
<br /> t. I.JNi2G3,VA.& GASDLINFe,3,Ff (I
<br /> 0
<br /> /� ,(y� 1 s7t31S
<br /> Z 2. UN1o`ro,V,'A.gTE FLAMFv'ifap el 0
<br /> `D ; c7LtfViw, C11 tCJ �7 l it tliC,404, dA PGIIi
<br /> 4.
<br /> 14.Special Handling Instructions and Additional(nfonnation
<br /> 9Ef-1)PROFIL �$�1i��ti ER 2� 9,�2)rROFI(A61.R. �SfUTetl�v,
<br /> P–=-R. -OR; RAS ,JOS Er1"IjOrgjv1iJ1T','j_ ERG#lW
<br /> MANDLI- SHoUi_f3 FjF TRAINED AND USE APPRa,/Eu PPE-
<br /> 15. GENERATOR'O/OFFEROR'S CERTIFICATION f hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified a a
<br /> marked and labeled/placarded,and are in all respects In proper condition for transport according to applicable international and national governmental regulations.If expo$shipment and I am the Pri kag d
<br /> Exporter,I 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 ry
<br /> Generator's/Offeroes Pdntew,yped Name 9 q ty generator)or(ti)(ifl am a small quantity generator)is true. I
<br /> } p Signature Month Day Year !
<br /> /t?Y t� Gi � ;r c '' A //F��
<br /> I u.international Shipments J' C, r
<br /> ❑Import to U.S.
<br /> Transporter signature(for exports only): ❑Export from U.S. Port of enky/exit:
<br /> 17.TransporterAcknowledgment of Receipt of Material Date leaving U.S.; -i
<br /> Transporter l Print!!Inyped NaTer`f�f f
<br /> SignaWre,,,
<br /> j Month Day Year !
<br /> Transporter 2Printed/ypedWe `
<br /> // Signatiffd""c'
<br /> Month r Day Year
<br /> t8.Discrepancy
<br /> t8a.Discrepancy Indication Space
<br /> r
<br /> ❑ Quantity ❑Type
<br /> ❑Residue ❑Partial Rejection ❑Full Rejection
<br /> 8b.Aitemale Factlity(or(3enerator) Manifest Reference Number.
<br /> U.S.EPA ID Number
<br /> acility's Phone:
<br /> 8c.Signature of Aitemale Facility(or Generator)
<br /> =MonthD—ay Year
<br /> 3.Hazardous Waste Report Management Method Codes(i.a,,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> i.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> inted/Typed Name
<br /> 4llll' '� f r1 Signature
<br /> Month Day Year
<br /> irm 8700-22(Rev. 2-17) Previous editions are obsolete,
<br /> r'ff arm,A w- --_.. ._. t
<br />
|