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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS I.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CALr, 0.t^(cwt i' 4 J J K 5.Generator's Name and Mailing Address 71 r,•R7" 1' Generators Site Address(if different than mailing address) .4i�ir]S OiL C_1.•STCrC!�:T_rF) EJE rii;ir IIV:•)�1 h:,yGRA00F.AIA! fav?fdA•v'i FF0. c;�,CR�,f�IENTO; 95391 Generators Phona::,.,,•�,,-�_�.; 6.Transporter 1 Company Name U.S.EPA 10 Number "rr,iTiOS �i9?rIRGi'1(u)ci�;iAL a.r�4C'cS ii1C. 1.Transporter 2 Company Name CMAC 4 40*3 55 5 � U.S.EPA ID Number (.�. jAi'v',.) 1,Vv B.Designated Facility Name and Site Address Gia r?.CIFIC RESCU2C_P r•: U.S.EPAIDNumber 331=0&4&T NICO 5LVO. CAC003252�IS LOS ANGELES,Com. 90022.7- Facidys Phone:300-499-714f oa. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(f any)) 13.Waste Codas No. Typo Quantity W(JVoI. oa 1 1401.�r3,WASTE GP.sOL!ME,3,PGR call Ohs G 34"3 � COO1 I CO18 2.W O i 3. 4. I 14.Special Handling Instructions and Additional Information I ! 98-1)PPOFIL5 IOiiCUG ;=%G:•123 =.R. COKPACW: PAtvfOS E?jVROAIAlVrr.AL HANDLEF:S SHOULO c=T F?.A?,150.A1O iJSE.4PPF,•OtjcO PFc X J5 15. GENE RATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of INS consignment are fully and aecwately described above by the proper shipping name,and are classified,packaged, marked and Iabeledfplacarded,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 EPAAckrwwk kpent of Consent. I cerlify that the waste minimization statement identified in 40 CFR 262.27(a)(if 1 am a large quantity generalor )(if I am a small quantity generator)Is true. GeneratoeslOffeWs Printedffyped Name Sig a Month Day Year OF I /�iyYj I� $ �- -4 16.I emalionel Shlptive ❑ Z Import to U.S. ❑a Xt from U. . Pod of entrylexi Transputer signature(for exports only): Date leaving U.S.: 17.TransporterAc$umdedgmentl of Receipt of Materials Transporter 1 Printedfryped Name Signature Month Day Year Cn O J Transporter 2 Prinledliyped Name Signature Month Day Year t- �-/lIa `✓ / /r� / 18.0iscrepancy 18a.Discrepancy Indication Space El quantity ❑TYPe ElResidue ❑Partial Rejection ❑Full Rry'ec6on Manifest Reference Number. 18b.Alienate Fac*-(or Generator) JU.S,EPA 10 Number _ V ear FacFTlys Plane: w 18c.Signature ofAllemate Faciy(or Generalor) MaFth day Year Q Z 19.Hazardous Waste Report Management Method Codes lie.,codes for hazardous waste treatment,disposal,and recycling systems) 1' 3• 4. 0/ 1 2 20.Designated Facility owner or Operator,Centrrcalkn of receipt of hazardous materials covered by the manifest except as noted in Item 18a Prinledffyped Nana y Signature M)onOr pay /Year EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. ;cSIG �,;;EO iLITy TO DES TINT IOM STATE(Ii`REOUIREt7)