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Please prinfor type. ERATOR )- UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
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<br />2. Page 1 of
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<br />3. Emergency Response Phone
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<br />4. Manifest
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<br />Tracking Number
<br />16963 FLE Generators Name and Mailing A ress ...... Generator's b Address (if different than mailing ac
<br />iltAGRA LiOTTLING, INC i I: im3R-A li(.)1' I LW*
<br />i 025 PUNWAY LIV:i-i .'I-i j (5 2,!-:',. mc!fl'Alli, 1 !,3F.I ,;' b:
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<br />GeneVORI;g4PN Li's' jtif-li4 1 $1* Octr, I c.:M 4 $:...:A. 9t;AR..i.
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<br />Transporter 1 compasyNaiie -4 • 0 o ,. . "4 il; I ,, U.S. EPA ID Number
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<br />FiWift 0 #'41,4PtirIAL 11. i.'HEMICAI Cfilkk k .;-1 .1LI lNl".:4 itic- I t:' A. R 0 0 0- 2 4 ! 4 4•' Transporter 2 Company Name U. EA ID Number ,
<br />1 Designated Facility Name and Site Address U.S. EPA ID Number
<br />CElliktillki Oa "T.riansfet
<br />f::-.700 Claus- Ril • ,
<br />FaciirMr ocier*- C'A 35:567 I CAL 9a. 9b. U.S. DOT Descnption (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total
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<br />12. Unit
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<br />F.H,A and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes
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<br />Wort-RCRA 1142;arthAA• NiSte Uquia (04 Voite.,;•, 77- 1 ) ,) 62 -,-;', 2:3 , GEM
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<br />14. Special Handling Instructions and Additional Information
<br />011:v VoLATER. - PR.O# . ..-80.1.ECC. PQ 0,4:4715 ralmity‘ day
<br />CA 92317 WC*
<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, act are classified, packaged,
<br />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 .
<br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent.
<br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if lam a large quantity generator) or (b) VI am a small quantity generator) is true.
<br />Generators/Offerors Printed/Typed Name Signature Month Day Year
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<br />16. International Shipments .:I Import to U.S. Export from U.S. Pon of entry/exit:--- -
<br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials
<br />Transporter 1 Printed/Typed Name . Signature r, Month Day Year
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<br />Transporter 2 Printed/Typed Name Signature Month Day Year
<br />1 1 I .4-- DESIGNATED FACILITY 18. Discrepancy
<br />Discrepancy Indication Space LI Quantity Type 17 Residue Radial Rejection Full Rejection
<br />Manifest Reference Number:
<br />Alternate Facility (or Generator) , U.S. EPA ID Number
<br />Facility's Phone: I
<br />Signature of Alternate Facility (or Generator) Month Day Year
<br />. I 1
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1. t i,... 2. 3. 4.
<br />. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded) m 18a
<br />prinflediTyped Name
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<br />1 Signature 1 /
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<br />Month Day Year
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<br />EPA F /06-2 (Rev. 12-17) Previous editions are.6-6solete. TRANSPORTER CO
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