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SSL SK SHIP# 223742i5u <br /> I?!lase print or type. Form desi ned for use on eRa(12-pitch) pewriter. 0 6 9 9 3 3 1- <br /> Form <br /> �, 9 P 11Y } Form Ap rovod.OMB No.2050�96 <br /> �+ UNIFORM HAZARDOUS 1 Gene 1pr10 Numhor 2.Page t of 3.Emergency Response Phone d.ManlfOst Trapkfn Num r <br /> ,. 0 5 338 1 1 �F3�R1-4 B�1760 <br /> YJASCi~NfAHI��SI v U 1 ' 3 31 5 i7: <br /> 5 Gi3i acetol a a'e,olid �1iing"Address Generator's Site Address(If different than mailing address) <br /> x1a �t# f� " st eririe <br /> ` Itf�riVa' S T�� I+ Co a+urN ltlf7 , �s U.S.EPAIDNumlFer ' <br /> f , <br /> n�JBffne T� (t{�pt �f�+ y(�y U,S.EPAtl3Numbat 1A /g 7 fry ty <br /> trA <br /> ['IADO.]' <br /> KS <br /> 45 8 i1e11] #tl I e t - U.S.FPAID Number <br /> '� ��f� LLC <br /> CA 90744, <br /> �� ►.i <br /> „� r,: h1 Na tt1 fas`if1'N ober" 10.Cooiairsars <br /> A Irk+ u � � � t' 11:Toter 12.Unit 13.Waste Codes <br /> lU,f'w a,"u r' k� r '- i - f r No 7"g Clsl&ntlt�r, Wi.Nol. <br /> �r ( rl _ <br /> t i- <br /> f <br /> v <br /> 7 <br /> 1 � <br /> 146 11 <br /> 14.Special Handlinr]Instructions and Addlt onel Information TSD C W l 74730676, S1�680 C$01 <br /> r <br /> �CROEHCY.til— alt- - i 7C > ( ! 1 ) � <br /> it e: go <br /> 1 "GENEitASOR'SIOFF t3R'S CERTif tCA ION: I hereby declare the the contents of this consignment are fu11y and aectrrately descnhed above .>✓tfie propel sfilpping name,ori#arw h 1 E <br /> diatked and labeledlplacarded,and ate in all respects in proper condition for transport eocoMing to applicable international and national governmontaf regulations:If export shipmctl! <br /> ti. <br /> r , Experier,I cerl+fy that the contents of Ihls consignment conform to ti,a terms of the attached EPAAckriowledgmerst of Consent <br /> •r,�f.r ,.,',a•:. ,. i <br /> I cetll#y That rice waste min3mhation ataloment Identified in 40 GFR 282.27{a}(H I am a largo quantity generator)or(b)(HI am a small quantity generator)Is true: +� �" y i •*i�i'�y+�lryi r',;; <br /> Geueratoe.dot or'sPrintedflypedName Slgtialure h <br /> i <br /> El <br /> t .� 78 uttadiandnal5t<iprstenis � v�,yb , rr' <br /> Import to U.S. ❑Export from U.S. Part of entryloxit: <br /> E w=" Tfpn$pgrtarsigoatur@,{tor expoltsonly): pate IeaWng U.S.: <br /> 17:Trahsp6darAcfVto�4tedgment of Receipt of Materials <br /> j: Transporter,!P ole. $ped Name Sig a re Month : ar <br /> o� { <br /> 'y Scans 'der2Pdtst Nairtoi <br /> t� 4 <br /> r 1r <br /> t nous <br /> Motiltt' <br /> g ara- <br /> C <br /> aV <br /> 18;fliscre enc <br /> R Y. <br /> 18a.Discrepancy Indication Space <br /> ❑ Qdan6ly , ❑Type ❑Residue ❑Partial Rejection ❑Full#teJ9Ctlan <br /> `r Man fest Refe€ance Number. <br /> 1 tib,Atfemale Fae ftty(or Generator) U.S.EPA Id Number <br /> C. <br /> u; Facility's Phone: <br /> 18e.Signature ofAte{nale Fadlity(or Generator] Month fJey Year <br /> Utg.Hazardous Waste Report Management Method Codes(is.,bodes for hazardous wasta treatment,dispdsaf,dn"recycling gysfetns) <br /> LL <br /> t , 1 2. ." A. <br /> 24.Designared Eacdk Owner ar p CC for Gedifratlpn of recel t of hazardous materials coveted the manliest except ded,lti Ile 18a <br /> tY p P Y p )5 <br /> Prinibdl ypea Name S"hobos <br /> nJ Month <br /> f �r4i41Fd t 44] Rd?f, S} PfdV4SVs editions are sblele. <br /> C3 SIC(VATE - -ACILI�'Y'Y'in,.DIwS";;INA7ipI�-57'A�'�(i�'!j� ;-_- <br /> i� s,�ih�f <br /> i <br />