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Please print or type_(Form designed for use erne 12-pitch)typewriter.) ( ` i� ,: Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS f.Generalor I Number 2.Page 1 of 3. ncy heide 4,Nanikst T2&j Number ry <br /> WASTE MANIFEST t 1 f C� f �F G JJ K <br /> 5.Generators Name and MaNig.Address Generators SEMffress(if different than mat ng address) <br /> P E} 15�37�/9 CA 913Bri 4840 N.8r"r9rfr rove <br /> Gerdfdrabrs S1104M.CA 95M5 <br /> { 1 Company►carne U.S.EPA ro Number <br /> +r!trrY rig sptz$ (A(_rA10.IW% <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> t3.Designafed-Facility Narnew4lSda Address U.S.EPA ID Number <br /> 4,ti VlT1 H*rb0-`S MrAW&AW 1_1 C 75?7ki <br /> VYyfX k•!1�crM�T lxeY <br /> Fadlttys Phone.A 1 71.Z-Qu <br /> ga. 9b.U-S.DOT Description(ulduding Prq er Slipping Name,Hazard Class,m Nwnber, 10.Containers 11.Toil 12-Unft <br /> HM and Psciting Group(if my)) No. Typa �", WtNd 13.Waste Codes <br /> W <br /> Ix <br /> 2. <br /> LU <br /> d <br /> 3. I <br /> 4. i <br /> i <br /> 14.Special Handling Insbuc6ons and Additional k0onnaflon <br /> i 144A4-,rt i E1¢iTt P.P F. <br /> 15, GENERATOR'Slt)FFF1tOR'S CERTIFICA :I hereby dnxJare that the crnlards of tis consignment are fully and accuralely described above by the proper shipping name,and are dassified,packaged. <br /> marked and labeledfplacarded,and are inaG proper condition for transport according to applicabletrrternatierdal and national govemmerft regulations-If export siipment and'i am the Primary <br /> Exporter,I artiy anal the contents of this�n t conform to the terms of the attached EPA Ad nuivIedgment of Consent <br /> I arty that the waste nwirt+oation statemettl identified In 40 CFR 26227(a)(d I am a largegvantity generator)or(b)(if I am a small quantity generarnr)is true. <br /> GeneratorslOtieror's Printed/Typed Name Signature Mordfi Day Year <br /> 16.International Shipments <br /> f— L lmwp'U.S. ❑Export from U.S. enbylexd <br /> Transporter signature(for exports only): Date leaving U S.: <br /> w 17.TransporterAdawirledgmentofReceiptof <br /> Transporter 1 PdMedfTyped Name signature,,, !/ Mdnth Day Year <br /> 11212 1 A-1 I <br /> ZQ Transporter 2 PdntedfTyp6d Name I swig re Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space E] Oar ty u Type ❑Res due ❑Partial Rejection ❑Fut Rejection <br /> Manifest Reference Number. <br /> 18b.Altemate F-acilily jor Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Faciliy'sPhone: <br /> w 18c.Signature of Akemate Facility(or Generator) Monty Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Mathod (ie.,codes for hazardous waste treatment,disposal,and recycling sysian s) <br /> 1 H2. . 3. 4. <br /> t <br /> 20.Designated Facility Owner or Operator.Ce' n of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PnntedITywd Name Ir- 't Signature MorM Day Year <br /> —+--- <br /> EPA Form 810(22(Rev.3-05) Previous ed'dions re obsolete. J - DESIGNAIfd)FACILITY TO GENERATOR <br /> All <br />