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Please print or type. Form Approved.OMS No.2050-0039 <br /> UNIFORM NA7AR[]0115 1'Generator 10 Nflmber <br /> 12.Page 1 of 3.EmergencyResponse Phone 4.ManilestTrackfng Number <br /> WASTE MANIFEST C A L .Q 0 0 4 2 4 E '! 7 goo e24-9136 02n'351004 JJ K <br /> 5.� ' Y �l�gAMHT LINE INC. G��Lr r� t l � ' <br /> 600 OLD DOMINION WAY 601 DARCY PARKWAY <br /> THOMASMLLE NC 27360 LATHROP CA 95330 <br /> Generator's Phone: 3 3 6 8 2 2 5 7 6 0 <br /> 6.Tr rter an Name U.S.EPA ID Number <br /> art r�vl oMental Services C A D 0 5 3 8 6 6 7 9 4 <br /> 7.Transporter 2 Company Name 6 b , ; ,, r Y U.a,EPA ID Number <br /> ,8:Oe��iljtyl�i�ess U.S.EPA ID Number <br /> 1830 WEST 17TH STREET <br /> LONG BEACH CA 90873 <br /> Facilitya Phone: 800 827-8729 C A 0 2 8 4 0 9 0 11. 9 <br /> 9a, 9b.U.S.DOT Description Including Proper Shipping Name,Hazard Class,ID Number, 1D.Conlalners 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(ifan)) w Ne Type Quantity Wtfvol. <br /> �� - 5 ►dal f. �Rck pp3c7 N°2. <br /> W <br /> � G P <br /> 5 Uj ikv) NAY0cAyl�s305 <br /> 31 <br /> 4.���17�l-'�l ILt`�0►Y�i�� Lc)dl5 J❑ 1 LA[�PJ�CI�� C7�1 �� L.L�; � 55 <br /> 14.ftya tvft"- f In <br /> Fo..H.. : L <br /> 3 19) �J_:...:...:.......• :- -.-.._,. .. <br /> a 3�� )LP-�53aS <br /> 02 037 15 <br /> C,A b�8; CA 47., (-,A Lf bg L �53� 3 <br /> 15..GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare•Gat the contents of this consignment are fully and ap�fately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabaledlplacarded,and are in all respects in proper Condition for transport according to applicable inlematiohaland 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 EPAAcknowiedgment of Consent. . <br /> I certify that the waste minimization statement identified in 4D CFR 262.27(a)(if I am a large qua eneralcr)or(G)(if I am a small quantity generator)is true. <br /> G neratoesfOff r!. Print drr ped rme SI Lure Month Day Year <br /> .International shipments <br /> F . . ❑import to U.S. f ❑Export ko Part.of entrylexit: <br /> ? Transporter.signature(for exports only): Date leaving U.S.: <br /> ; ',•'u.?J ransporferAcknowledgment of Receipt of Malerials <br /> a Transporter 1 PrinledfTyped Name ((�jjUUn <br /> ( SignaZ <br /> Month Day Ye <br /> CL <br /> 011 - 3 k <br /> 1 <br /> Z Transporter 2 Printed(fyped Na Signa ure Month Day Year <br /> F- <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity Type Residue <br /> ❑T ❑Partial Rejection ❑Full Rejection <br /> ❑ <br /> I W-REFERENCED <br /> µ R t BR <br /> 18b.Allemate Facility(or Generator) I)lSP0SAL,TREAT?-W.NT OR REI,S$CROSpY a OV FRf> r T�rE FAL'rL1TY.O i t <br /> EY'RAITTS,GIIANTFD TD T1 tFH.AY.11IE DEPAATME.',fr'AF:]�pXIC Si1f157ATiC'E Lti,YTRO[:;7'dGi[3 i.:. . <br /> U - •- � ,• HTr}{TFtE FS1Y[RONAI nrt'AL3'Fpa-'=]t}Y AGINCY�LN ACCORDANCE wr'rH_n[E PROVIS10N3 <br /> LQL FacilityrsPhone: OfE RESOURCE CONSERVAT7011 AND RECOVERY AQF 076 T000nUR WTrlf APPLIC.16t:. <br /> Lu 18c.Sonature of Ahemate Facility(or Generator) r T IUE �-06 G=Ats,Day Year <br /> F LMM TO ACCW n[E RFSiRFNCED WA;T AND ALL 71M NVAST•E <br /> HAS FLEIT MI-F). <br /> Q nrrtnmre r <br /> y19.Hazardous Waste Report Management Method Codes(l.e.,codes for hazardous waste heatment,disposal,and recycling systems) <br /> a7 1 I 2.///// <br /> 13. <br /> I 4 <br /> 20.Designated Facility Owner or Operator,Cert ficat on of recsipf of hazardous maledals covered by Hie manifest except as kted in Item 1 B <br /> Prinledrryped Name Sign atur Month Day Year <br /> zft <br /> -04Qg (Rev.12-17).Pm ous hitions are obsolete. <br /> tDE5[GNATED FACILITYTfl GENERATOR <br /> r <br /> 'r <br />