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Please print or type-(Form designed for use an elite(12•pitch)typewriter) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2.Page 1 of 3.Eme oncy Res ansa Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CADS $ 2 0 3 D 7 v ' 1s �'�' � 018853844 JJ K <br /> 5.lj""VikwssP= n ator Ite dr diL Iffereq[than mailing address) <br /> 14W DuXMMS Street-Slop 1000 833 E M Street�0� <br /> CNMhe NE 8$179 S&WACI art CA 95M <br /> Generators Phone: 9 1 Is 5 4 0 « 0 4 9 6 <br /> 6.Transporter 1 ComfA Name U.S.EPA ID Number <br /> Amit!iean Q;ted Semices, Inc. C A R 0 U 0 1 4 8 3 3 8 <br /> 7.Transporter 2 Company Name U.S.RA ID Number r <br /> KrIle C c+ <br /> 8. i n Fi� anii . dress U.S.EPA 14 Number <br /> 16M W.I M SgUe tt <br /> Long Beech CA 9W13 <br /> Facili 's Phone; SW 41W-sw ICAD028409019 <br /> 9a- 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 WIJVol. <br /> x <br /> 1. wm Yosie L.1*m tus ed M 221 <br /> 0 01 DM G <br /> Ill <br /> LU 2. iA�I Sura SPNO) 141 <br /> ch D DSII03 <br /> - -- - <br /> 3. <br /> 4- <br /> 1a.�I�NarIrt `9n4 � m °�ndlinq. Weights or volumes are approximate. . � <br /> AIS aob#79023-18 / 't;21505 / 9a.1: 1111528 9a.2: 111529 <br /> 15. GENER'ATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this oonsignment are fully and accurately described above by the proper shipping name,and are classif ed,packaged, <br /> marked and lab eledlplacarded,and are in all respects in proper condition for transport according to applicable international and nalional governmental regulations.If export shipment and I am lha Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowiedg sent. <br /> I certify that the waste mini mizat on statement identified in 40 CFR 262.27(a)(if I am a large quantity genera[ )or(b) f I am a smai rq4 generator)is true, <br /> Genera rs(¢ffer�Pr�rTygecJ,�lame gna a Month y Year <br /> AAttS pin oTT[[Xneratar J.HougMa ft 7 l <br /> 16.international Shipments <br /> P- ❑Impart to U.S. D Export m U.5. Pon of entrylexit: --- _T_—_. <br /> z Transporter signature(for exports only): pale leaving U.S.: <br /> W 17.Transporter Acknvwtedgment of Receipt of Materials <br /> III Transporter 1 Printed/Typed Name Signature Month D_y Year <br /> N tit gTz TU o� ` 3 <br /> .< Tr A 22 Pr�yped Name r 5fgnature Mont�h+- Day Yea <br /> N <br /> tj� d 1 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Afternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> ua Facility's Phone: y <br /> 18c.Signature of Alternate Facility(or Generator) Month Da Year <br /> a <br /> x <br /> y19.Hazardous Waste Report Management Method Codes(i-e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> A 1• JJ 2- <br /> 20. <br /> 20.Designated Facility Owner or Operator.Ceruficalion of receipt of h ardous materials covered by the manitest except as noted in item 1 Be <br /> PrintedfTyped Name 5 gIf <br /> Month Day Year <br /> EPA Form$700- (Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />