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f <br /> 412366-16 l' C R I. Ig?6 u 5• ' J• / // / 2355034 <br /> SUP for use on elite(12-pit6t),typirriter.) (�2 r •� \ Form Approved.OMB No.2050-0039 <br /> Ueneralorl0 Number .; 2.Page 1 of 3.Emergency Response Phone 4.Maddest Tracking Number <br /> CE610GOb-13752 I 1 E877) 577-2669 OODJL2857 DAT <br /> 5.Gem!ratofs Name and Mailing Address .-I , Geaeralofs Site Address(it different than mailing address)' <br /> Simit ftefir4 Son ices ' Suit Psgafin Sunces ' <br /> 703 IDdestrial Park Drive 103 ln&strid Park Drive <br /> Gerwrator's Phone: Hadeca CR 93337 (299)923-3062 Hdnteca (Yd 93331 (299)023-3052 <br /> 6.Transporter t Company Name U.S.EPA ID Number <br /> 21st Cen u Env ronnental iianaaeoent of California LP CAR000210617 <br /> 7.Transporter 2 Com cry Name U.S.EPA <br /> ID Number <br /> Z67Z- <br /> 8 <br /> Z- <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 2W CEtI11L9Y EWIG9i,n 1f1 rfu4;.r� 9f CEM, LLC <br /> .2095-0= (3 UE MST <br /> FariNysPhone' 17?9 $15-2760 NVD980805336 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.TOUT l2.Unit 13.Waste Codes <br /> NoType Ovantl <br /> HM and Parking Group of any)) ry WtNol - <br /> . . <br /> 7-M-1993.WE ama-rE LIIPJIDS, N.O.S. (6)TiM SPI@ITS, E901 DO10 F093 <br /> RA fiASKIM 3 PBI.T091D001=10OLDS) Df9 P <br /> W 215 <br /> z 2' MINA A'AIPrRDOMS nSTE, U111119 (0113 UTE61 n 223 <br /> Q9 <br /> Y D(4 _ _�QG P <br /> 3. <br /> t , <br /> 4. <br /> 14.Special Handing lnsbuctions and Additional Information <br /> (1) 153722-00 - ER6(I29) HIRED SIILGIIIITS (2) 732190-09 OILY fflED <br /> 15' GENERATOR'SIOFFj!!ROR'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 IabetedlpWcarded,and are in all respects in pmper oundition for transportaccording to appli able Imemalimaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I caNfy that the contents of this consignment conform to the tends of the attachad.EPAArknmdedgmeot of Consent <br /> I caddy that the waste minimization statement identified in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(AI am a small quantity generator)is We. - <br /> Gen tofsy0ffbmfs PnntedrT arae Signatu Month Day Year <br /> tf <br /> U <br /> J 16.Imematimal Shipmen <br /> F- ❑import to U.S. ❑Export Wm U.S. Pon of en**t <br /> = Transporter signature(for exports only): Date leav' ON.: <br /> IX 17.TransporterAdmowlecigment of Receipt of Materials <br /> Transporter 1 PnntedlTypatl NameSign r <br /> Month Daly Year <br /> 141 y �r.�F I dl ave �'�� � -1 <br /> Transporter 2 Printedi7yped Name SigpaWra Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑TWe ❑Residue ❑Partial Rejection ❑Fu0 Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> rd,+. Facililys Phone: <br /> uu 18c Signature of Alternate Facllily(or Generator) Month Day Year <br /> Q <br /> z <br /> H19.Hazardous Waste Report Man gement Medwd Cedes(i.e.,codes for hazardous waste oammml,disposal,and recycling systems) - <br /> 0 1. ' I 2. I 3. 4. <br /> 20.Designated Facility Ow a or Operator.Certification of receipt of hazardous materials covered by the ma rimd except asin dem 18a <br /> P. yped Name 5ignmu M th Day Year <br /> A PY <br /> EPA Form$700-22(Rev. 5) PkWus editions a obsoete. - DESIG _ STATE(IFREGIUI D) <br /> 12376.0125 6 <br />