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Please print or type. 4 C 7 7 7 0 a 7 9 8 K S <br /> Form Approved.OMB Na.2050-0039 <br /> UNIFORM HAZARDOUS t Generator ID Number `x F 00l"O 1 `�� 2,pays 1 3.E e�fwAe 4.ManifestTrad Numher <br /> WASTE MANIFEST u�� � O O 17�o g�s s Ks <br /> 5,GSA; —KLEEN enerator's Mame and Mailing Address Generators Site Address(idifferent than mailing address) <br /> t=0 aux :3 5 SI;FtTY_.l f.C:t+ S1S7?P}S ;j`,L, <br /> �rir ; 3050 <br /> Genera0' —345--4 0.1 <br /> Generator's Phone: <br /> Y 5 TIL t+};, I P;°,;- U.S-EPA ID Number <br /> i RK!LAOQFS 1 Eof <br /> 7,Transporter 2 Company Name <br /> U-S.EPA ID NumFer <br /> S.Designated Facility Name and Site Address 5A!'ETY-KLILLN OF CALIFORNIA U,S.EPA ID Number <br /> AVE.- <br /> NEWARK 94+5E.0 <br /> FaciliiPhone: CAD 9'8+0S87,+ L, <br /> ga. gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit <br /> No. Type Quare ty Wt.Nol 13.Waste Codes <br /> 1. �JliN-RC:RA HAZARDOUS l PIS T E r LIQUID TT {i c2; <br /> � � ova <br /> Z 2. <br /> LLJ <br /> 3. <br /> 4. <br /> 14-Special Handling Instructions and Additional Information T SD C E V <br /> B SRL <br /> L411 EtgERSEtdC,Y#800-468-176 +-C;H/St5/TFI-Luntr-act retainea by genrrrator• Canfers ag envy atktmor ;' q, <br /> On initial transporter to acid or substitute aaditional transporters on eneratar' s behalf. <br /> 75. GEHERATQR'SfQFFERQR'S CERTIFICATION: Thereby deGare timet the contents of this consignment are futiy and accurately described above by the proper shipping name,and are classified packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intematfonai and national governmental <br /> Exporter,I 9 regulations-If export shipment and I am the Primary <br /> certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if t am a small quantity generator)is true. <br /> GeneratorslOfferors PrintedlTyped Name t Signature Morf Day year <br /> (A . Iz Z <br /> J 16-Iniemational Shipments <br /> F L1 Import to U.S. Export from U.S. Port of enirylexit <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Admowledgment of Receipt of Materials <br /> � Transporter 3 PrintedlTyped Name nature <br /> Sig <br /> CL �r G 1,, �'�` �� Month Day Year <br /> Y Transporter 2 Nnted/Typed Name Signature <br /> Month Day Year <br /> f- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ 4uantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility{or Generator} Manifest Reference Numher <br /> U.S-EPA ID Number <br /> V <br /> Facility s Phone; <br /> Ujj 18c.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> Z <br /> 1 g.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1611 <br /> 1 F ki ' 2. ____T3. <br /> 4, <br /> 20.Designated Facility Owner or Operator-Certification of receipt of hazardous materials oovered by the maNlbst except as noted in Item 1 Be <br /> Prin yped Name Signature <br /> C1. Month Day Year <br /> £P�FC .$7,.0( 7,7{�v p]�7} Previous editions are obsolete. <br /> -• '�- Jzi DES TED FACILITY TO EPA's e-MANIFEST SYSTEM <br />