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Please pont or type:(Form designed forAuse on elite(12-pitch)typewriter.) i;„ Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page,t of 3.Emer.ency Response Phone 4,Manifest Tracking Number
<br /> WASTE MANIFEST A,L o o O 9 4 4 3 fl 1. t8af?) a 43Q0 01405441.7 JJ K
<br /> 5.Goner O 61-1,' ppd less "' 4°' 1t.'r'"v1113%r'Geherators SIWAddress(if different than malting address)
<br /> 1648 E.H AMMR LN.
<br /> STO'CKTON CA 95210
<br /> 24�A52 7�0.
<br /> Generator's Phone
<br /> 6.Transpo c ""n Lg1t ua n�I 1rA d
<br /> ,rxl r r aa EPA_Ii u r r�a to ,&' I
<br /> ��SFF '91 �1Ru� s .. . y> r: n
<br /> 7.Transporter 2 Company Name U:S.EPA ID Number
<br /> 8.Desi a Ig
<br /> pi`:'4t5,I�C�.,d�1`��L�IES LLC U.S.EPA ID Numbere
<br /> 5375 SOUTH BOYLE AVENUE 1'.i.°8t)n±,t :,: :• ,':,;, "
<br /> LOS'ANCELES CA 90058 CAD 0 9 7 0 3 0.9 S 3
<br /> Facility's Phone. '
<br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,.Mazard Chs{D tV nbert,nta�71;; a 00:Containers. Tl• 11:Totalr. 12 jUnl4' i) 13.4Vasle Codes
<br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol.
<br /> O r!�Ii:9L•1 r{4 115b",;fl! :'Inn br"C 111,91 '2':" '•'- '
<br /> 8F tin.u rrl
<br /> W 2.
<br /> G7
<br /> 3 i
<br /> r
<br /> 4.
<br /> 14.Special Handl in 41twetions and Additional Informaliatt `
<br /> E�9F}3 Ncy CONTACT:CHEMPIEC 1-90D-4V4300 N11MV 901:171 *PROFILE#@BA 'AP199199 OILY SCUM
<br /> APPROPRIATE PEf'SOW PROTECTIVE FEN'!
<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of.this consignment are f0yand accurately described above by the proper shipping name,arc'are classiflod,packaged,
<br /> ma?,(ed and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemationai and hational governmental regulations.Ifexport shipment and I am the Primary
<br /> Exporter,I.cerlify that the contents of this consignment conform to lire!arms of the attached EPA Acknowledgment of Consent
<br /> I'cerliFj L`tai the waste minlm!zatiof,statement identified in 40 CFR 262.27(a)lift am a large quantity generator)or(b)(91 am a sma l_quantity generator)Is true.
<br /> Generator'slOff6forts Ptlntedrryp'ed;Name ( ,1, Siaturo Month Day Year
<br /> -r. 16.International Shipments Im l.to U.S. by
<br /> ❑ pc ❑Export from U.S. Port of en lexil:
<br /> Z ',Transportersigriature(for ezpott'snnfy): Datetleavirg'U.S.
<br /> W 17,TranlporterAcknowledgment of Receipt of Matena!s
<br /> t" Tra f rt n t Pdnted(kped Name Signature �'` Month Day Year
<br /> drY �? r �:
<br /> 7,Z, `;T� r .! �,fie:f,-e...-• f_ 7; '_•„� ,e�" '',_;,,ie�".,.,- .�-.�""''"-~'. r.+�..1� .Cr ,I:f:•,.
<br /> rn ,
<br /> Z Transporter 2 Pnnted(Typed Name I S gnature Moth ' Day Year
<br /> rl .
<br /> 18.Discrepancy
<br /> IBe:Discrepancy Indication Space r
<br /> ❑T ❑Residue '
<br /> ❑ Ouac6ty tips Partial Re;eclion Full Rejection .,
<br /> Manifest Reference'Number. &t
<br /> 9b.A terriate Facility(or Generator) U.S.EPA ID Number
<br /> J
<br /> iJ'
<br /> Facfity's Phone:
<br /> C3 16c.Signature of Alternate Facility(or Generator) Month Day .Year
<br /> . Q '
<br /> Z -
<br /> 4 !S2 19.Hazardous Waste,Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recychrg systems)
<br /> 1110 1, .. 'p_ 3. 4. ..
<br /> 20.Designated Facility Owner or Operator:Certificationof recall of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Printed(TypedNan'tai I L Signatu•e Month Day Year
<br /> 116
<br /> EPA Fgrm,87170-22(Rev.3-05) Previous editions are obsolete. l% TRANSPOrRTER'S COPY
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