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t„,ener3tAr 34 4-4-f-4-es that no nnMait3t change has occurred e@lw fit the o'Nractert4fos or In the pr.t es5 generating the rn Left ,- Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone Manifest Tracking Number WASTE MANIFEST - 4. U11.4%--J6111,58- 6 F L E 5.Gener t rs ame ad Mail' dress Generator's Site Address(if different than mailing address) ci +t ar�of rafi�� i I rc�s.3t�� 3019 Loomis€d .3. 3AM Stacktcn,CA 452K-1 Generators Phone:(21,191467-7340 6.Transporter 1 Company Name U.S.EPA ID Number art r< arbalrs Environmental 5mic es,Inc;, Irk .A 1-1 t y d 3 2 :t! 2 5 7.Transporter 2 Company Name U.S.EPA ID Number e. ''�"' -^�'' _j.. t r- i I fig ! < M 0Tii 0r' r6xPq �tif.�}. 1t ` t d' t✓ �)1f i 1 t, 8.Designated Facility Name and Site Address w - °°° - U.S.EPA ID 4dr116er Aewji all Ar w.,a s ita LOC RR /Y^�� ,��y1�q 2 t.Y i.E " i3 .%. .r.� C.1 17 1160-0 N,ttoithFAow s Road Facility's Phone: {+c?519offi..9100 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1.UH3_09,"WkT'%kDRGANICPEROXIDETYPE V,L!QU!0', X WEA'OX AC s its:ACAD.MCA 5.2 z 2. } w t9 3 i 4. r 14.Sew g I"s, ons and Infor Wei a mation G"111 ac:t ieti{r1 tJ L :,ettefwt�f 1_;rPfef w,2-'Rz" ?lT110rfirj OD InF[43i Tr3nSp4i,�'r 10 nit+7 i; 5i3t7�Ztit{T@ aQdtttvnar tfariSL�Ft?rc 0(1 s'atla r�7(itr`r hpTr n r C:trrii, nit i ntirt.i. .LTi,^:tan- r•rmAtstOri,c n - 4 ... . .15. GENERATOR'SIOFFEROR'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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)("m a small quantity generator)is true. Generators/Offerors Printedrryped Name Signature / Month Day Year 16 tethatbridl Shipments / p ❑import to U.S. ❑Export from U.S. Port of entry/exit. ? Transporter signature(for exports only): Date leaving U.S.: ! W 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 Printed/Typed Name Signature Month Day Year Zq, 29- Z Transporter 2 Pdrited/ryped Name Sign e } I Month Day Year 0 ;1 18a:Discrepancy Indication Space ❑ a Quantity tity ❑Type' ❑Residue ❑Partial Rejection El Full Rejection y Manifest Reference Number: 18b.Alternate Facility(or Generator) { U.S.EPA ID Number J _ U tai Facilitys Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year N19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1 0l. i1 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a ( Printed/Type d Name Signature / (Month Day 1201 � ff I EPA FoL%Rq",%y.i1aa Ttt@ a} r�3TE t�iptasr3Tt r NdtN 3Ct8pt$ilE lq mtfi fltG"gtrT@18t4.f t Shlfly�3{Iy"• ''DEVP DF T �TQ G NM OR