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Please orint or tvoe. (Form desioned for use nn PUP. (19-nitrh1 lvnPwntor 1 . n„t, ,: C....., n <br />10355.0402 J <br />UNIFORM HAZARDOUS <br />1. Generator ID Number2. Page 1 of <br />3. Emergency Response Phoney <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />t. AL O D O a 8 "� 3 17 9 1 <br />,znn) 4e3-371 a <br />0 01087957 F L E <br />5. Generator's Name and Mailing Address . Generator's Site Address (if different than mailing address) <br />Tz7m; iz Ctm, T- 9 523 <br />280 SpracNe1�AVe <br />i'T)Fn?P-ca , CA 95335 <br />Generator's Phone 209 87. 9982 Ate: Revtei=-e Lcq Jv cs FrocQS�-Or <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Clan Harhor EnviionniQmBI Se cas Inc N A D 0 3 9 a 2 2 2 5 G <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />"�" �✓ L.7 (%T i � c�J -74 -11 L <br />8 Designated Facility Name and Site Address U.S! EPA ID Number <br />Ci, -2n Haf�Q1 s Amgonle LL.0 <br />14300 Ncrt% 1ptu� Road U T 0 9 8 1 5 5 2 1 7 1 <br />Grz:ntsville, UT 14029 <br />Facilites Phone: (80i'l <br />ga <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNoI. <br />I UN 1057,W_A=. 1-113HTERS OR UGHTER REFI! LS,2.5 <br />DQ01 <br />343 <br />rY <br />0 <br />X <br />,NONE <br />001 <br />Dal <br />G 001 0 <br />P <br />Z <br />2. <br />W <br />0 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />LRGTO LP 1 Y,5010 0 xO2DP IPS 1 nF� <br />E9fC 6,1117c�=1 FLEE-- ff442i(a 121-V TAR Gl-=T-0211 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />General s/Offerors Pdnted/Typed Name igna re f on ay ear <br />y� <br />3 0-2 115 108 <br />1�� 1(j /%% Z (� v Z /�t�t JGY1 <br />J <br />H <br />16. International Shipments - <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter si nature for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Ix <br />Transporter rneypeame Signature Year <br />a <br />SeenCn <br />Z <br />Trans er 2 P ntedrr ed ame g� r Month Day. Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantty ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manliest Reference Number <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Q <br />LL <br />Fac li 's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />a <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />0 <br />1 � V <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator Ce ' cation of receipt of hazardous materials covered by the manifest except as rated ip Item 18a I <br />r <br />Printed/T� Name Sg� <br />natur ` . 1 th Day / ,Y <br />1j V <br />( PM9M-4NQ,a(ReCSS ,. a�„fl ob.e �r�rr r 1._QE44GNATED FACILITY TO GENERATOR STATE IIF REQUIRED <br />10355.0402 J <br />