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, <br /> Pte print or e. Form des( ned far use on elite 12- itch typewriter) "'RT: , trr� r a x � ;, n Form Approved. OMB No. 2050-0039 <br /> ase p typ ( g i P ) hrP ) <br /> UNIFORM HAZARDOUS 1 . Generates I0 Number 2. Page 1 of 3. Emergency Response Phone 1. Manifest Tracking Number <br /> WASTE MANIFEST Cen �C�QNumber i 1 8GL1'924E© G4 dress) 552 FLE <br /> 5. Generatoes Name and Mailing Address Generators Site Address (i1 different than malting address} <br /> S ( MS ) 016896 US <br /> c'"03823998C 280 5}ireckel ! Ave , c': ui (' w C 280 SPY . CIIGIS CVC , suite S <br /> Generator's Phone: iidPrtt? ca , Cil t13Q%j6 f_'q 9533n <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> ateriryrlo SpaIvialty Wass a Saluti , om irc ' NNN1Gr @1 '. l%r ;c1r <br /> 7. TranspoRer 2 Company Name U.S, EPAID Number <br /> 8. Designated Fad6tyName and Site Address (oneral Cn '! ? ronupntil Mgt ., LLC U.S. EPA ID Number <br /> 1 F 055 Wh i t: a Roc '{ Road <br /> Rancho Carrin �� 3 , CA 03742Faciity's Phone: 9 16 3b 10980 CAD913AF: 41 (i3 <br /> ga• 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, 10. Containers 11. Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WtNol. <br /> ( 1 >,iNC81 : , On . Le To ; it: Dol idF, , organitc , 116 Oe , . 1 CF 0LlQJ ? ^ 3f ?. L1w►O7 0910 <br /> o ( Ciu ' uI"! imia , S0. eft ; u ,0 . 6. 11 P6 TJ , LRG#: 151i <br /> W Cant girl ad , 1 U 0%0?11 P 311 Pool <br /> ( flarfarin ) , <br /> PC ERM V <br /> 3. <br /> 4. <br /> 14. Special Handling instructions and Additional Information 1 . 1 OJ@ 195 ( R X T o is i r Saltdca 100 7 9 ; R e '> x d u c w e i e ;T t Joust; n 0 t <br /> cxceed G- 0436 ? bs ) CMT : 11 <br /> 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, <br /> marked and tabetedrplacarded, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. <br /> I certify that the waste minimisation statement identified in 40 CFR 262.27(a) (If 1 am a large quantity generator or (b) (a I am a small qu generator) is We. <br /> e r sl eros Pdntedrryp d Name � CJS gres na ay �r <br /> t4 V 1^'� t;3 iE, aG ;. 7 <br /> _r 16, nleff* nal Shipments 0Import to U S E] Export from U.S. / Porti er ytexit.• <br /> tTransporter signature for expods only): Dale leav' U.S.: <br /> W 17. TransporterAckr wledgment of Receipt of Materials <br /> OTransporter 1 Printadriyped Name 9na " nthy , ear <br /> a . Jared at ciel t3 0+`. . f) 1 l <br /> Z Transporter 2 Printed/Typed Name gnature montn Day Tear <br /> 18. Discrepancy <br /> 18a . Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J_ <br /> V <br /> um Facility's PhonBONN <br /> e: <br /> 18c. Signature of Altemate Facility (or Generator) Month Day Year <br /> j y 19. Hazardous Waste Report Management Method Codes (i.e„ codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 \ ` 126 , 3. 4. <br /> 4--j{ <br /> ` <br /> 20, Designated actii y Owner es Operator: Certification of receipt of hazardous materials covered by the manifest except as noted,"m tem I" <br /> J <br /> homommuffim <br /> I PhniedriypedName t signature / Month Day Year I <br /> Vy '0V <br /> A/ T let <br /> EPA Form 8706.22 (Rev. 345) Previous editions are obsolete. ' DESIGNAYi IiD FACILITY TO GENERATOR STATE JIF REQUIRED) <br /> I <br />