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Pie se print or type, '4 Form Ap .OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number ; a g R Manifest Tracking Number <br /> WASTE MANIFEST , 14. <br /> 0 017 9 3.4.1.4., VES <br /> 6.Generator's Name and Haling Address YULISSA OALVAN Generators Site Address 01 different than mailing address) <br /> FED E%4ROLIND BATA <br /> 5655 HOOD WAY <br /> TRAC`•Y,CA 453'71-7217 <br /> Generafofa Phone: <br /> 6.Transporter i Company Name U.S.EPA ID Number <br /> VEOLIA SS TECFWAL SOLLMCING N J D 0 8 [1 6 3 1 3 6 9 <br /> 7,Transporter 2 Company Name U.S.EPA ID Nymber <br /> 8,Designated Fadilty Name and Slte Address U.S.EPA ID Number <br /> VEOLIA ES TEIM-IIkUCAL SOLILM 3NS <br /> 7 MOBILE AVENM <br /> SAUOET,IL 62701-1069 <br /> Facillty'a Phana: I L D 0 9 8 6 4 2 4 2 4 <br /> 901. 9b.U.S.OOT Desorption(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Well 12,Unit 13,Waste Codes <br /> HM and Packing Group(H any)) No. Type quantily WiNol. <br /> 1' TJM197,WASTE SIGNALS. -91i L4GSf� r D003 331 <br /> v� f 30 1 DM 3 P D001 <br /> �( 2' NA3178r WASM n OKELE99 POW1N.'PM ffi7 ` � 101003 <br /> (100 POUNDS OR LESS,4.1,1 j`rry <br /> 1 DM 8 P 331 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EP t3en+ire Caghmac#ed by VEtiT8 -)- Coa4ac•1 retained by pxziel:a#uur confess <br /> %ngauthority an initial taaspocter to add or m*diw additiowl to is rs on gleenerartnr's bOaaM + I)W:595z33 A: <br /> 000595233 N.S.W.=112 p&aM 2)E1?_GA33 W.592f)H3 A•. 92083 <br /> 15. GENERATOR'SIONFROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and aocuratoiy described above by the proper shipping name,aid are dasstiied,packaged, <br /> marked and Isbeladlplacardad,and are to efl respects in proper coudlUan for transport according to appflrable International and naeonal governmental regulations.ti export shipment and I am The Primary <br /> Exporter,I certify that the conlsnts of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. <br /> I certify that the waste Wrilmizallon statement identified in 40 CFR 262.27(8)Of I am a large quantity generator)or(b)rd I am a small quantity generator)is true. <br /> GeneratorWfferodsPrintaVypedName Signature Month Day Year <br /> LISSR LV <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of ertryiexil: <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> W 17.Transporter Acknowledgment of Recelpt of Materials <br /> FTransporter 1 Printed/Typed Name Signature Month Day Year <br /> JON,SILAS 1H � C/ <br /> Transporter 2 Pdnl QA*d Name Si nature Month Day Year <br /> ( -t. <br /> 13111 <br /> 18.Discrepancy <br /> 111a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full RaJedba <br /> Mantfest Reference Number. <br /> 18b.A tamale FaOly(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management U90M Codes(i.e.,codes for hazardous waste treatment,disposal,and racyding systems) <br /> H940 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials coverod by Oma manliest except as noted' m 188 <br /> PrinlodlTyped Nam Signa Month Day Year <br /> EPA orm 8700.22(Rev.12-17) Previous editions are orsolete. of DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />