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e sc Ppw 7ri2r�oi8 <br /> Please print or type. Form designed for use on elite(12-pitch) er.). r7 t�o 3 Form Approved,QINB No.2050-003) . <br /> tINIFUR[N NAZARDm 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest racking Number <br /> wASTe MANIRST r~w!.o 0 0 i 0 a 1 d� 483 719 011974318 FLE <br /> 5. s N e and f�itipg dress Generator's Site Address(if diffefent than mailing address) <br /> w. r :t` 252&w w1nst, a <br /> gam, 5kodet.CA 95203 <br /> GenemWsPhone'.. 700.. AT'fi�litTiit HtR <br /> I rar�s r nylliame U.S.EPA ID Number <br /> T.Transporter 2 Company U.S.EPA ID Number <br /> 8.Designated Facility Nara and Address U.S.EPA ID Number <br /> CWMHWbWSBUMMMM1kWLLC CAD 9 B'0 8`7 52.7 6. <br /> 2500 Weatakffft"Read <br /> F s hone: Ch 932O6. <br /> ga. 9b.U.S.DDT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HIM and Packing Group(if any)). No. 71 Type Quantity M.Nol. <br /> Ix 1".kWjj59 1M.N.0_S_PP RIC..CHRDMUEHI r 571 <br /> P0,111. ASH <br /> ! 47 Y7 zap 19 <br /> 2. �. <br /> 3: <br /> 4 <br /> 14.8---W—Han N»tuctions arid Aldi o rmatwn <br /> : <br /> MmsMer <br /> to. nal tSMIRlM on s <br /> t5. GENEtA'f4R'O"bPXERO S.:C MICCATM:1 hereby.declare#W the canterda of this consignment are fully*d ecciirat9ly described above by the proper shipping name,and are classilied,par aged, <br /> marked and labeled/placarded,and are in all respects inpropBroonditiarr*transport according to applicable irydp ilatuoflat and national governmental regulations,if export shipment and!am the Primary <br /> Exporter,I omify that the contents of this o3mignment conform 0 the terms of the attached EPA.Acknowledgnierh of Consent. <br /> Inert fy thattha taste minimization statement identified in 40 CFRI62.27f a){'d t am a large qumrtity.generatoij'or(b)(j(am a small quantity generator)is true. <br /> y ame. SignatureY ear <br /> 16Antomational Shipmen*I <br /> ❑import to U.S. ❑Export from U.S. Porl of rylex. <br /> Trans fof exports only): Date Ieavi U.S.: — <br /> QG 17.. dgmsnt rA RgrAminf M rials <br /> 1 yped Name y r <br /> Transpoftw yped Name. gn a ay. <br /> yea <br /> 18.Discrepancy <br /> lea.Disaepancy-Indicatio.n Space ❑.Quantity ❑Type ❑Residue ❑Partial Re)ection ❑F,0 Rejection <br /> MM Re&rence Number: <br /> 18b.Alternate Facility(or Gene€ator) U.S.EPA 1D Number <br /> v <br /> FaciNtys Phone: <br /> yet 18c.Signalure of ANemalk Facility(or Generathr) Moro Day Ye rr <br /> a <br /> S2 19.Hazardous Waste Rebut Managentertt Method Codes(ke.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 11 20Designated Facrlity Owner or Qperator.CJerfficetion of recelrt of bazardous matetfals covered by the manifest except as noted in Item t <br /> .� E"y6 :�:Qam <br /> Pdntedffyped Name Signature oath Day YeEr <br /> EPA Form 87130-22(Rev 305).Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> CIO 0 HWbW4 bis the appiopdoa ponaks,for and.WIN&WqA.ttfle waste the SHMMOr is ddPON&. . <br /> _.....�:.._,�.,.,.�: .,. -.-:., t;.ti,w �..�.:wa��,-�-:-.a+rwa+-«'.`�vr.^Nr..9.`•.y.p+cu�,�.... - _ _ - <br />