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�y Please print or type. Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.P >'1 of' e�q se Phone 4.Manifest Trackiing Number WASTE MANIFEST, C A L 0 0 0 4 2 4 8 1 7 tfU�bL9-'J� ti 020350"666 J J K 5.�c�t '��I ` HT LINE INC, r �Cf 'f l fl� 4l1�lR616 T�''_'Mdf . 500 OLD DOMINION MAY 601 DARCY PARKWAY THOMASVILLLE N 27360 LATHRaP CA 95330 Generator's Phone: 3 3 6 8 2 2 5 7 0 6. nParsNmental Services r BNudb% 8 8 0 7 0 4 7.Transporter 2 Company Name • U.S.EPA ID Number 8-�eciidress U.S.EPA ID Number 9:630,WEST 17TH'STREET LONG BEACH..CA 90813 Facility's Phone: 800 827-6729 C A D 0 2 8 4 0 9 0 1 9 ga•. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit . HM and Packing Group('d any)) No. Type Quantity Wt:Nol. 73Waste Codes 1 t,(W1165 W0. %;14 I_ ci1YJMA N . LU 2. '1� &4'A3ta5 Luets -(?lhc,%Zji "—eA _ qb f �� ITS 1 _ cob c-�k �! p LP55440-!PETRocH M-_.,PO# x36588 14I� aII�a4 �luctq„P�dA, B'alforp �,19-00365 -19 CA4772, CA4849, CA4:880 1DI 77 b© (�7 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accihtgly described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in a1I-respects in proper condition for transport according to applicable intemationaland'national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if,1,am a large quantity generator)or(b)(ifI am a small qx:u60ty generator)is true. Generatoes/Offeror.s Printed/Typed Name Signabw. Month Day 1 Year aA 16:Int ional Ship j_... _ __ - ❑Import to U.S. _ ❑Export from U.S. Port-of entry/exit: . K Transpo er signature exports only): bate leaving q.S.: W- 17:Transporter Acknowledgment-of Receipt of Materials Transporter 1 Printed/Typed Name �' Sign atur Mo Da Ye z Transporter 2 Printedfryped Name Signatu Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue l ❑Full Rejection yP Partial Rejection Manifest Reference Number: F 18b.Alternate Facility(or Generator) U.S.EPA ID Number _J U. Kiri?RPXERENCtp NVAM WAS RTX >u-)'J!% fEU AND STORED FOR SL'85EQ'.IE'if O l SI7T � Faclliry'S Phone: UISPOSP?.TS;:A'`i�=•r•- r Or RBL. C"fS OV e? ON INC.O ';'1 r:5'SIiF rRC::.11Y Uh��4 ro TY k Cu'vr OL T- - fk iii 18.c.Signature of Alternate Facility(or Generator) t 1.Lv v r o < 3 r t '`«°r° -” µ�� Q' R -. ss-A.CI?C�=i' - - •:N An.,-�F;, ''�L:�'1 A'I•.lia s tUt; ;r ' -IrFr ht°"i-t Alit.y Year Z - - s• \L AND ST'' F..�..0_tom 1 'S. CFOSBY fa VERT_N r ALL _;P'1 . 'NECES AR11 F-1 N 14A Y 19.Hazardous Waste Report Mana -T. _AZ .gement Method Codes(i.e.,codes for hazardous waste treatr",d o`s5��na recjrrlid�sysfeiiis)LU "- k/0 20.Designated faciiii-owfier or Operator.Certification of receipt of hazardous materials covered by the manifest except as nded in em a8a Printedfryped Na -- Signature Mont Day a EPA Form 8706-22(R .12-17) re bus editions are 6bsolete. DESIGNATED FACILITYTO GENERATOR