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Please print or typd. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS t Generator to Number a.Page 3 of 3.Emergency Response Phone b.Manifest Tracking Number <br /> WASTI=MANIFEST `40 0131411 i M A �13� 9 20409650 JJ K <br /> 5.Generator's Name and Mall Ing Address Generator's rSke Address,r if different than mailing address) <br /> NW, 116 .10 MUMMA cal <br /> o��t � 1g E <br /> Gene�aLo.s Ph❑,A i @@ <br /> 6.Transporter 1 Company Name 11.5,EPA ID Number <br /> 7.Transpo ter 2 Company came U.S.EPA ID Number <br /> S GeslgRated FaoiMy.Name and Site Address EPA ID Number <br /> Facility's Phone: 1L5 <br /> ga• :'36.U.S.GOT Descripfian(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 19.Total i2.Unit <br /> HM .' and Packing Group(If a±ty)) No- Type Quantity Wt.Unit <br /> [::l�'NaA6, es <br /> 1. <br /> 40-MA fl-PARD0015-WAW WNW (W L-) <br /> L <br /> • 3. <br /> 4:':". <br /> 14.5 ai Handling I Wtructiorls.and Additional Information — <br /> � �� ��� <br /> SOB 4 69 -to-00 ib <br /> 15. GENERRTOf2'SIE7FFEItOR'S CERTIFICATION: E hereby declare that the contertfs of fhls consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlpfacarded,and are in ail respects in proper condition for transport a000rding to applicable international and national governmental mgulatlons.If export shipment and I am the Prfmary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of <br /> Consent-certify that the waste minimization statement identltied in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(]fl am a small quantity generator)is he. <br /> Generato' Offeror's Printadffuped Name Signet re Month Day Year <br /> _j 16.1nternauonal5hipments <br /> ' 46 <br /> p ❑Import to U'S. E_.l Export from U.S- Port vf1entry/exit; <br /> z Transporter signature(for exports onfyy Date leaving U,S•: <br /> W 17.1ransporterk1knowledgnrent of Receipt of Matedais <br /> UJI <br /> Transporter 9 PrintedlTypetl Name 5[gnafure Month clay• Year <br /> 2E Transponer2 Pittedffyped Name Signature Month flay Year <br /> 18.Discrepancy <br /> 18a.Discrepancy lndicatlon Spars Quar&ty Type F7 Residue ❑Portia!Rejection ❑Full Refec@an <br /> IZ _ <br /> 986,Alternate Facility(or Generator] Manifest Reference Number. t1.5.EPA Ip Number <br /> C7 <br /> u<,. Fadlftj'e PhG�-ia: a <br /> 1 c-Signature of Altemet Facility{or Generator] Month Day Year <br /> LU 99-}fazard0us Waste t&port Management klethod Codes(i.e nodes for hazardous�.faste traa€rient,disposal,and recycling sysients] �� <br /> 2. <br /> =4. <br /> 20.Aes'rgnM M Facility Domer or 0peratar;Cal-IN efion of receipt Uf hazardous ms€eriW 1-avers4 by the manfmst exeapt as noted ie.Item 18a <br /> Printed yped Name Signature MGnih Day Year <br /> EPA Form 8Tfl0 2i(Rsv.72-17; Previous ediacns are obsale �� "`� <br /> DESIGNATED FACILIT'� 1:11,11��A's em10AN@FEST SYSTEM <br />