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Please print or type. <br /> UNIFORM HAZARDOUS 1.GeneratorlD Number Form Approved.OMB No.2050-0039 <br /> WASTE MANIFEST i 2.Pag�Emanc;y e Phone#�c..�tl1t0�,07 f35 4Manliest Tracker <br /> enerators Name and Mailing �}Generators Site Address(if different than mailing address) t 3 <br /> t�'.ttDiDT1e ..$3�� <br /> 094779788 2309 W Hammer Lane nutOz13Tte##3328 <br /> Generator's Phone: Str3Cjlttt37. rn 23119 j• aMMer' Lane <br /> 6.Transporter 1 Company Name 95220 3 <br /> StLiCj{tOf7 <br /> 7. <br /> ter`iCv^�,e b ec;ialj, � oSte Solution Tt[ tU.S. <br /> ui EPA ID Number <br /> Transporter 2 C mpany Name 00 <br /> 110924 <br /> LZO 1,.— L –1 �� U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address C>."�n t� <br /> eIIG C121lfgC <br /> 41 Isis RvenuE U.S.EPA ID Number <br /> !Inglewood, Cf 9 1301 <br /> Facility's Phone�C,�,77i�("j2,;;3 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, CAD0083 443 . <br /> HM and Packing Group(if any)) -10.Containers <br /> 11.Total 12.Unit <br /> o: N3_16WaSte CDrroSive Solid, basiCg e3d) No. Type Quantity Wi 13.Waste Codes <br /> rtor�ganirWg n. o. s. (Sodium Car� onate31. <br /> , g ' <br /> W1p <br /> PS II ER #154 <br /> : ® LTID <br /> W 2.. <br /> C� <br /> 3. <br /> t <br /> 4. <br /> 14:Special Handling Instructions and Actditionxl Information s <br /> oda <br /> 15. GENERATOR S/OFFERpR'S CERTIFICATIpN:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shrppm name <br /> marked and reify that <br /> the conte and are m all respects in proper condition for transport according to applicable mtemationaland national governmental regulations.ff e <br /> EXporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment n Consent. g and are Gasified packaged, <br /> I rbfy that the waste minimization statement identified in 40 CFR 262.27(x)(d t e a a c a export shipment and I am the Primary <br /> 'Gene tors/Offerors Printed/Typed Name ' r9 quantity generator or dl am a small quantity,O( q ty generator)is true. <br /> ' Si naturo <br /> 110111111 <br /> ...r 16 International Shipments Month Day Yeah <br /> ~ ❑Import to U.S. <br /> ransporter signature(for exports onl ❑Export from .S. ' JET <br /> Y)' Pott of e /exit t <br /> W 17.TransporterAcknowledgmant of Receipt of Materials Date I <br /> Transporter 1 Printed/Typed Name ng U.S <br /> Nn #t#ifl aCk Sig ature <br /> Transporter 2 Printed/typed Name Month Day Year <br /> 1 L] Sgnature <br /> 18.Discrepancy Month Day Yeah, <br /> 18a.Discrepancy Indication Space EJ <br /> Quantity E]T <br /> YPe EJ Residue <br /> ParhatRejection <br /> ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) <br /> --r Manifest Reference Number <br /> U <br /> u Facility's Phone: U.S.EPA ID Number <br /> W18c.Signature ofAltemate Facility(or Generator) <br /> a <br /> z <br /> N19.Hazardous W t Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Month Day Year <br /> G 1 <br /> 2 n9 <br /> 3. <br /> 20.Designat Fac 4• <br /> 9 Owner or 0 gator.Certification receipt of hazardou materials covered by the manifest ce t as note ' I <br /> Printed/Ty Na <br /> �/� p 18a <br /> V •U Signal <br /> e <br /> EPA Form'8700-22(Rev.12.17) Previous editions are obsolete. Month Day Y r <br /> DESIGNATED FACJU ' 0 Epll'S;g�r NI E 1 <br />