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05 08/201a 11:47 3232612,_L <br />■.'(Fomde�hod for on elite 12-phktypeviriter.) <br />I Generator ID <br />PRR SYS DIY PAGE 01/02 <br />Frim AnnrnVArl MIA kln InVA41mo <br />ri-Arorin 8100-u tRev. M5) Prevfous editions are obsolete. TRANSPORTrER'S COPY <br />HA.Wbous z Page i Response Phow 4. ManHesl Tracking Number ���� <br />ra r 2. Page lol 3. <br />210 9 JJK <br />�5• Genprotor.: Name and MdEngAddross <br />(Jt)or; muswm ar TRACY <br />R 30 AUTO 1107-A WAY Ile) <br />'YRACY (.,-A 5 MWA <br />Genemtoes PIMS: <br />6. Tiansrity i -Company Name - <br />P. l-'Tr'AT COAST I.M.10003 U.S. EPA ID Nmber <br />C, A R (XV) I W 4 1; I I <br />7. Transporter 2 Company Name U.S. EPA ID Nurrabar <br />8, DosIgnated Facility Name and Site Address <br />PACIFIC RZSOVRCF rMOW(-.I�.Y U.S.EPAIDNwnbef <br />',MO EAST PICO BLVD. <br />(.QS ANQTCl.C'.5,- CA 90KA23 <br />Fa4lity's Phoria: ( fs(o ) - 4 99•-7 .l ;1, <br />ga, <br />9b. U.S.DOT Discripr= (incloding Proper S(1p"�11,g?lamo, liatard Clws, ID Niunbcr.uf�' <br />bars <br />11. Total <br />12. Unit <br />H&I <br />, &Wcl& <br />Paq Group (6 any)) <br />nRY <br />fflivol. <br />13. %lam. Codes <br />No <br />Typo <br />1.VF4.I,-/QAA <br />0 <br />ul <br />Cl� A N'T M 13 0 L t I I'l 0 W 1VORPI lleo <br />ONLY <br />1,33 <br />14. Hand - ,.Ins truct3ons"Addi alinfoinnallon <br />- t 44 �'t . �l <br />0 -1?9r 4' 96 AP f. -I 3 <br />GLOVES, 008GLES & MWITfJYV11- CLOTI-UNG 24HR I"MrRGENCY (XI`4l'AClJ'JlZK <br />r.'R01- J-)bl) 12-5 91;,4) NOW. <br />TRAW;PPRTER I PHONE 0 1-4188-770-f,1162 <br />Is. GENERATOWSIOFFEROR'S CERTIFICATION: I her* declare that N contents of this conslawent efe-irtilly acid accurately described above by 0e proper sWppfng nom. "ace dasOad, packaged. <br />marked and Isbeled1p1mrded, and are In of respects In proper cWi5on for trumpod according to opp' cablo Inlemallonal and Patmrw govementaJ regulations. If export sWprre'nt and I am the I'Amry <br />Exporter. I certify (bat the contents of ft oonslgnment conform to the terms of the allached EPAAcknovAedgmenl of Comerd. <br />I certily that the waste ifiln"ation statement Idulfle d In 40 CFR 262.27(a) (f I am a large quantity generator) or W (df oma.1moctuantityge. is ho. <br />eraloraK)Herof/(s?d'n1i`edlTM; Name MDCiN Day, Year <br />J <br />-j <br />16. International Shipments <br />0).P.t to U.S. ❑ Export from U.S. `t <br />Pod of entry? <br />Transporter signature (for exports Dray); Data leaving U.S.: <br />M TrP=pxWA*"lWqrmnt of Recolpt of Materials <br />.e <br />0 <br />O. <br />Tran*yt I Pribledayped NameSignaliffe �10A!47 �ar <br />Tarnsporler 2 PdnledfTyped Name We <br />Month Day ''Yeat, <br />Disorepancy <br />j18. <br />18a. Discrepancy Ind;w6m Space El Quantity Type Ll R"J. PerCel Rej'ecllon F.1 R.IvA. <br />Mariifesl Reference Nvinbler: <br />18b.Allmmale Facirly (or Generator) U.S, EPA ID Ntimbef <br />C3 <br />18c. Signatwe ofAltemale Facidy (or Genemtor)I <br />Dwo'L h Dal -ar <br />19, Hazardous Waste Report Management Method Codes (Le., codes nor hawdousHaste treatment, disposal, and recycling sys(oms) <br />0614 <br />2. T <br />-- <br />20. DesIgnaled FaclWayner oe Operator: Coitkallm oftecelpt offiazanious rraleria!s cooemd by the ranlqst except as rioted In Item 18a wq <br />fttogyped Name Signature <br />�jr ItX / a . '4 mouthmouthDay (e <br />ri-Arorin 8100-u tRev. M5) Prevfous editions are obsolete. TRANSPORTrER'S COPY <br />