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L r fU q l <br /> s' 888055-1.6 DTSC. ,3663'12461 <br /> R@pse lett or type.(Form designed4or use on elite(120tchl typewriter.) ' i (� 2331n 3733 <br /> oproved.OMB No.2050-0039 <br /> WkIFORM'IWARDOUS 1.Gemuahx ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number' <br /> WASTE MANIFEST P 000119324 DAT <br /> 5.Gen Name and Mailing Address Generator's Site Address(t different than mating address) <br /> Sumif OoofiRg 52epices S=ir' Ors8filla Services <br /> 705 IDdustrial.Parif Drive "I IDd8s4rial Park Drive <br /> Generators Phone: S <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 21,;t Cpn+ijrryu nvironmentil IjAmqf-manf- of California , IP 7 <br /> 7. n ver 2 Company Name - U.S.EPA IO Number <br /> N <br /> ` H/ evVIC D <br /> 8,Dsignaled Facility Name and Site Address U.S.EPA ID Number <br /> 21ST CEW,Y ENUIRQ.SMAL EMEMH QF M02, LLC <br /> 2095 MMMS ME EAST <br /> Factil e's Phone: FYIKILFy. tT Rg4flfl <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers I .Total 12.Unit <br /> HM and Packing Group(I any)), - - No. Type Quantity WtNDI. 13.Waste Codes <br /> 1M-RCU XWRDOUS-OSTE, LIQUID (OILY MEQ) G 223 <br /> o ® or, <br /> � r <br /> w 2. MIND MH TLR'ial-9DLE MID, IMMMIC, N.O.S. (TITRNI4i.7 DIOND D001 Dole F005 <br /> X IUNDifM1,. 1 ESTI}M 6.1 P6II V0001=100LDS) B DH elo0 P <br /> 3. <br /> 352 <br /> :.N <br /> 4. 1. <br /> 14,Spatial Handffg Instructions and Additional Information - <br /> r <br /> (11 IS2199-00 - OILY EATER (2) 752193-00 Ea5I1531 HM SCLUEMS, Ku <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acaatey desrnbed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplaarded,and are in all respects N Diaper condition for transport according to applicable inamatloaland national govemmenal regulations.If exportshipment and I am the Primary <br /> Exporter.I certify that the contents of this consignment conforin to the terms of the attached EPAAdawwdedgment of Consent- <br /> I mr*that the waste minimization statement identified In 40 CFR 26227(a)(t I am a large quan by generator)or(b)(f l am a small quanOty generator)IS hue. <br /> GerreaNrslO6emr's Printed/Typed Name Sgn Montt Day Year <br /> k P303 <br /> J 16.International 51himems,IF <br /> .r..(lore.a wm Imports U.S. ❑Expom from U.S. -Rod olemry ' <br /> Z Transporter si nature <br /> g aDory): D IeavWg U. .: <br /> 17.TrmaparlerAcbtoxledgment of Receipt of Materials <br /> T 1 PdntedTypeed Na s,'r.;+ . ' �:• Signetu Month Day Year , <br /> N i�(r � '� "• 4AA ------ <br /> 31 3 11 <br /> Zit Transporter 2 Printed7Typed Name Sig W Momh Day Year <br /> 18.Discrepancy <br /> j 18a.Discrepancy Indication Spam ❑ Quantity ❑Type <br /> ❑Residue ❑Partal Rejection ❑Full Rejenion <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J o <br /> U � <br /> W Faaliys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month, Day Year <br /> Q _ <br /> Z <br /> H19.Hazardous Waste Report Management Meted Codes(i.e.,codes for hazardous waste heabnen,deposal,and recyUmg systems) <br /> 3. 4. <br /> 14 <br /> 20.Designated Fatality Owner w Operator:Certification of mmipt of hazardous materials covered by the manifest axapl as Med in Itsm 1 <br /> Pnnadlf Name Signature Month Day Year <br /> EPA Fon 8 o 22 ev.3-05) Previous editions are obsolete. <br /> MDESIG TED FACILITY EWERATOR STATE(IF REQUIRED) <br /> PD 1. 6 2016 <br /> 12348.0343 <br />