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Please print or type. Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number c <br /> WASTE MANIFEST 002010364 VES <br /> 5.Generators Name and Mailing Address Genera ors Site Address(if different than mailing address) <br /> FM EX 431OLM SAME <br /> 5655 BWO WAY <br /> 6.Transporter 1 Company NaMV U.S.EPA ID Number <br /> VM)UA in 1BIUMM 20=0MN Ly 6 13 G 9 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> TAWAT6 NWOR 1IMSIT Co. IM 0 D 0 9 3 0 3 9 9 9 8 <br /> 8.Designated Facility Name and Site Address <br /> VE�IA 1R SAL tO �. U.S.EPA ID Number <br /> LLC. <br /> 1704 W.M9T t1'L'I= <br /> Facilitys Phone: gW AZIIAA CA 91702 C A D 0 0 0 1 0 2 !) $ 1 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group Of any)) 13.Waste Codes <br /> No. Type QuantityWtNol. <br /> 1. <br /> X UN12 3,WANTU PAW RIRAIW MATB[J&gg <br /> o O�II►TO F0U3 331 <br /> 0 PAW TE»M1.DR°PIIti ,FJ9MW 0.OR Rffi 1t1 <br /> t COMMAM,3.R RQ 1 D M 174 P FM W.3 <br /> W X 2. UN WASTE FLAWWAR8 ,T <br /> co:1(YI�T$ I80P>IiMPAN04.3.If ' FM U01 UW <br /> I D M 174 P 1FWJ U139 212 <br /> X 3 1M175,WASTE SOLMS CUNTALNM FL AMMAI E FM 1 352 <br /> LIQUID.n9.eMMM C�DI�tTAAtAMM WITH <br /> 11t7�L.VEtI�Tfi),21.11 1 D F 3 1 P DQDS <br /> 14. UNMB.Wi4STBoxQy?$QaoL!t QU� .�CgRRQ A% LX►t}3 L19tD <br /> a.o.�..(FERAiCEM AM HYDHQE�T�•5.1 <br /> C81s II 1 D F 21 P - D001 3311 <br /> 14.Special Handling Instructions and Additional Informationtoor �'� r ��_ f 4� <br /> A2r>cC�x�� 113 I191W�A. dubeII a d bdh>� � 1)�:IZ8 W�aOMI <br /> t AZLS = 3 �ESO;I9s al; A6DD6Tts411 B 1;140 WfflSM <br /> 4 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately'desdribed above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable Intemationaland national governmental reg$afions.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 26227(a)Of I am a large quantity generator)or(b)Of I am a small quantity generator)is true. <br /> Generatoes/Offeroes Printed/Type Nap Signature Month Day Year <br /> \Jl m6ii bG I tf 1i'1 <br /> J16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Pdnted/Typed Name Signatu Month Day Year <br /> s • �� T/ w <br /> .� rter 2 Printed/Typed Name Sig Month Day Year <br /> 9ALL �C✓ D <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue <br /> ❑Partial Rejection F]Full Rejection <br /> t <br /> Manifest Reference Number. <br /> 18b.Alternate facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> 114 <br /> Facility.Phone: <br /> W 18c.Signatute of Alternate Facility(or Generator) <br /> a Month Day Year <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 1 12. I 3. <br /> 20.Designated Facility Owner or Operator.Certification of Wipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> Pdnted/Typed Name Signature Month Day Year <br /> EPA Form 8700.22(Rev. revious editions are obsolete.' DESIGNATED FA IL TO EPA's e-MANIFEST SYSTEM <br />