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Please print or type.(Form designed for use Ion elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039, <br /> UNIFORM HAZARDOUS 1:.0 a analog ID Nwnber 2 Page 1 of 3.Emergency Response Phone 4.M if 7 �( <br /> WASTE MANIFEST it iI ra 5 JJK <br /> 5 CMwafars Name and Mailk Address Gefig=sq (if diSereat than matt"address) <br /> P 33M <br /> 1W N..&Vedway Ave <br /> ca,er�ork �' 10FS+&1.CA 013N CA $52M <br /> 6.Tra mpoder 1 cow" - . U.S.FPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> fid*NonfearclS�e U.S.EPA IDNuhirer. <br /> aaw�qwbom HiAtv-r-NrP4 if Lig£ ��7577tT <br /> IISM [tzkornRNA <br /> Fac;W,Phone <br /> 9a. 9b.U.S.DDT Description(including Proper Shipping Name,Hated gess,ID Number. 10.Containers 11.Total 12.Unit <br /> HM and Paddrg p(d Vin)) No. Type Quantity wt bL i3,waste codes <br /> � <br /> 1 d e�i r?' 42laf{f Cti:S T}'> 'ate�;+U( C1Ff�4lIT I�8I3fNs) C;?r/ P362 <br /> p <br /> LLA 2.LU <br /> i <br /> 3. i <br /> r <br /> 4 <br /> } <br /> 14.Special Handling Instructions and Addftnai information s <br /> . r.r?rS vPil:1.Y fSi'� 43't' sS:-. 1:.t;1t i_'•`hc.:�YS)) ---- - -- --.. --- -- --- -- ---.. . - - -"--- - ._ .._ <br /> %istir P':xc]i'P FIE- <br /> 15. GENERATOR'SIOFFEROR'S CERTIFIC ON: I hereby declare that the wntgtts of this cor>9gmn:erg are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> r'-,. <br /> marked and labeled/placarded,and are in 1 respects in proper condttiorr for tratLsport aaordirigte�applcable iMertratbnal and national govemmenial regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contlentsof ft c n%gmnent conform to tie terms of the attached FPA Adumiedgrnent of Consent <br /> I cer5fy that the waste minanization s idehlified in 40 CFR 26227(a)(d 1 am a large quantity generator)or(b)(d I am a qtty generator)is true. <br /> GenembestORemrs PrinfedOyped Nam Signature .4 Month Day Year <br /> - 16.International Shipments <br /> j* ❑Import to U.S. ❑Export from U S. of enby/exil <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> LCC 17.TranspoderAdmowledgrnerd Of Receipt of <br /> Transportyped Name_ , -Signature Month Day Year <br /> CL <br /> Transporter 2 Printedrryped Naive V / Month Day Year <br /> F- I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space D nay ❑Type ❑Residue ❑Partial Rejection ❑Ful Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL FacifilysPhone. <br /> Lu I ac.Signature of AftemateFacility(or a Month Day Year <br /> z <br /> N19.Hazardous waste Report.Management Me Codes(i.e.,Hoes for It�dotrs waste treatment disposal,and n ng systems) <br /> p 1. 2 3. 4. <br /> l—lJ3z a <br /> 20.Designated Facility Owner or Operator GertAom of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Month <br /> Day Y1ear <br /> Pdnted(ryped Name - � `., r5: - signature e <br /> EPA Form 870G-22(Rev.3-05)Pievlous edlfionlare obsolete. r OSIGNATE D FACILITY TO GENERATOR <br />