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Please print or type. Form Approyed.OMB No.2050.0039 <br /> -- 1.Generator 10 Nu nbe ) , ','�� 2.Page 1 of 3.Emergency Response Phone 4.Manifest TrackNuber <br /> UNIFORM HAZARDOUS 1 � �� 1 �/ <br /> WASTE MANIFEST 1vin-8�4' z 6 0 .970'3592 J J P+ <br /> 5.Gen tots,N a aling Generatoes Site Address(d different than`'�ng addre <br /> n, " Au� X11✓oq� 1,1,ntavl Pea 'c, f�a�l✓ <br /> b S'Z 0 Cvr1 �c- �Dr. 1 COO <br /> a:°V►a _►S �1� t{ C-o 9`i�� t-1�c Y►t Cc�v► CA <br /> Gmere s _) <br /> 6.Transpo ter 1 Company ame U.S.EPA ID Number <br /> _spofi -'��wlilyd✓t_��. __�J__�� —_— I C1�'OQZg'`•ia`Lc�►R <br /> 7.Tranrter 2 Company Narrc U.S.EPA ID Number <br /> 8.Dernaled 1,01y Add res U.S.EPA ID Number <br /> 1 10 1+11A <917 <br /> Faaliy'�s hone: i5aw,�, CA g6V3 — ----- — C.PrbcS Z TO 19 <br /> 9a 9b.U,b'DOT Description(uhcluduhg Proper Shipping Name,Hazard pass,ID Number, --10.Containers 11.Total 12-Unit — 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity _ NAPM. T <br /> CPPB£_��S_s�,�,i. M►'��---—--- --- --- -- — - ---- —{ - <br /> 2. <br /> 4. <br /> 14.Special InsWctions and Additional Ininrtnalbn .—.�— -- —^-- -- -- <br /> W Vl�ZO 00�61 f (�C <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the convents of this con*nment are fully and accurately described above by the proper shipping name.aid are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport accoding to sppkable intemalbnaland national govemmental regulations.N export sthipmerd and I am ton Primary <br /> Exporter,I certify that the contents of this consignment c iorm to the terms of the attached EPAAdmawledgmenl of Consent. <br /> I certify that the waste mininhvation statement Identified n 40 CFR 26227(a)(if I am a large quantity generator)or(b) small quantity generator)Is true. _ - <br /> Generator slOffoon s Pmte�dlT�gg-N — — —Signature -- Month—Day Year <br /> J I is, 1 1>na0onal Shipments i Import to U.S. l— J Export from U.S. Port of entrylexil: <br /> F- \\\/// Date leaving U.S.: <br /> ? Transporter signature(for exports only). <br /> W 17.Transporter Adaro�Nedgment of Receipt of Malerlair _ _ <br /> Transpor II Pnnted/T ame - —- Signature ! ZZDay Year <br /> O J <br /> Month pay <br /> Year <br /> a . <br /> yped Name r� r <br /> re <br /> N Tr n S <br /> 18.Discrepancy <br /> 1Ba.Discrepancy Indication Space F1 Quantity 11 Type El Residue Partial Real n ❑Full R*cuon <br /> _ Manifest Reference Nunhber <br /> 18b.Alternate FadAy(or Gerheretor) U.S.EPA ID Number <br /> V <br /> Facllitlls Phone: Mond pay <br /> Year <br /> w 18c.Signature of Alterrhate Facility(or Generator) <br /> Q <br /> Z <br /> 19.Hazy dous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 01 �� — 2. 3 <. <br /> �.. <br /> 20.Du sigma rakdltty Owner or Operator Certification of receipt of hazardous materiels covered by the man fest except as noted In Ilam 18a Month Day Year <br /> PrintedfTyped.Ntinrhe <br /> CD-r.:-..07 1 jailP-v-nn Arlihn,swre obsolete. 1-'�DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />