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Please print or type. Form Approved,OMB No,2050.D= <br /> UNIFORM HAZARDOUS 1,Generator ID Nurnbar 2.Pape 1 ai 3,Ernergdrwyr Neapome Phone 001796489 <br /> OtT , ��4 8 VES <br /> WASTE MANIFEST <br /> 5.Generators Name and MaNlrp YtLU"CALVAN (n anera thamawl,p addraes) , <br /> PM EX CIR OUND SAM <br /> 51955 S10D WAY <br /> JRA4 re't wne95977.=7 <br /> 6.Transporter 1 Company U.S.EPA ID Humt>ar <br /> D 0 8 0 6 3 1 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> M 0 D 0 9 5 a 3 6 9 9 6 <br /> B.Designated FarAlty Name and SltoAddress U.S.EPA ID Number <br /> • VBOLiAHS�� <br /> ZaT.I:'.. <br /> 17"W,F=SIR= <br /> Facill s Phono: AIg 13&4112 AVIA&CA 91702 <br /> 9a, 9b.U.S.DOT Domiptlon(krdAng Pieper Shlppkg Name,Hazard Claes,fD Number, 10.Conlaineta 111.16W V.Unk 13.Waste Godes <br /> HM end Packing Group(If any)) No. Type Quantity WlNok <br /> X <br /> LW3105,WAISTS OR 1AN1CP=XW5 TM D,UQM 0003 DWI $51 <br /> � �7�m.1�nm. rms,ol>mol�as�I�,ss <br /> F U160 DIW <br /> z 2. <br /> LU <br /> el <br /> 3. <br /> 4. <br /> 14.Speefal Handling Instructions andAddlilonal IMomratlors <br /> Sk$arvmCaalkalgWtiWVS19'!WI +Coftotatelt-l4►mmobwasiAn <br /> "M 1ai dR�1RlRW�MfapGlltfttoidll�Yt lltAOi Il1�1�s111ftEp! i b&d -i- I ROOMWY.715M A: <br /> 15. 05NERATOR'S/OFFEROR'8 CERTIFICATION:1 hereby declare that the contents of this omAnrnent are fully and accurately de8pl6od above byih@ proper Wppi g name,and ere claselfled,packaged, <br /> marked and fabeledlplacerded,and are In all respects In proper conMon for transport acoormng to applio"lntematkrnal and natlanal govammentel rbgulabons.H expert ahlpment and I am tlw Primary <br /> Exporter,I oe*that the oontenta of thIs corm1l;n wtoenfarm to gra farms of dw aWrHred EPAAckrawfedgment of Consent. <br /> I certify that the waste mWmlzatlon statement ktentt6ed to 40 CFR 26227(s)(11 I am a large gw0ty generator)or(b)(if I am a small quantity penara Is Info. <br /> Gene r torsfOffom(s Pdnted!)Yped Name Signa Mon <br /> . th Day Year <br /> -,,,r 18.Intsmatlonal Shipments , <br /> ❑import to U.S. ❑Fxpat fan U.S. Port of enbylex8: <br /> TroneporleT slgrw€m(for expaia only): Date leavlrg U.S.: <br /> 17.TransporferAckaowlKigrnent of Receipt of Materials <br /> Transporter 1 Pdnledn*d Name Signature Mo* Day Yaw <br /> 2 1 <br /> Trane ,2�r�edlT err SIa � mlonth Day� � Year <br /> v <br /> !i.WA <br /> 18.Discrepan <br /> cy <br /> 16a.Dlnctepancy Indication Space ❑ Qaerl$ty O Type ❑Residue ❑PadW Rejection ❑Fuk Re}ecd. <br /> Mentfast Refarence Number. <br /> S. 16b.Allemale Eadlity(or Generaloo U.S.T ID Number <br /> LL FaWVs Phone: <br /> 8 18e.Signature of Altemate Wily or Generator) th Day Year <br /> 19.Hwznaeus waste Rapart Management Method Codes(I.e„cones for harardaua waste habeent,dlapoeal,and mqd N eystems) <br /> 7 <br /> a 1. i 2. 3. 4. <br /> .F. <br /> 20. <br /> es net EadU orDpersilu-ceffllcaw of racelpt of fiqzardous materials covered b'y the fentfeat except as ndA loom I& <br /> Print Y <br /> - <br /> EPA Form 87 (R 12-fl) Are s edWons are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYST M <br />