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Piease print or type- Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Gsneraurn 2 Page 1 of 3 Emergency Response Phpne d.Manifest Tracking Number <br /> WASTE MANIFEST ;,AiLiXAAAA;ib6;y r, ..y , ;, .1 JJ K <br /> 5.Generator's Name and Mailing Address Generators Site Address;if dgerent than mailing address) <br /> PAM 11&1 Iffi, KOO(a#41L <br /> i 7'40 L I'ICL I Ffefd <br /> Al-A11AVNO_.L.A !6A%t0 <br /> Generator`s Ph <br /> 5.Transporter 1 Company Name U.S.EPA ID Number <br /> 3511 t:I(:Wv titAc L 1 1 JVh+I 1 k AI IMI. <br /> T Transporter 2 Company Name U.S.EPA ID Number <br /> ..L-A"LAK rtl <br /> 8.Designated FaciHty Name and Site Address US EPA 16 Number <br /> I!i1 ut-If T L tY t V*(C*tllFtif I Al WAW i kA NLVA1JA 1 i,. <br /> ,'411i'�h�VY'k.MYClS fiR FAST <br /> Facility's Phone <br /> 9a 9b U.5 DOT Description rinauding Proper Stripping Name,Hazard Class.ID Number. 10.Contamels 11 Total 12 Unif 13.VvVas:e codes <br /> HM and Packkrg Group(if any)l No. Type Quainbiy WT'voi <br /> I <br /> Q <br /> W � <br /> V <br /> 3 <br /> 4 <br /> 14.Special HandliN Instructions and Additiorrai Information <br /> f_M 1, VKLA ILLA 11/Attj, UU •1.`%A-Li L-JA u1L.1 A4 kAGO sl 1 <br /> Mf k F-?4-Y ":-*VAt'T '„If'Te'tkIA <br /> 15 GEN ERATOR'SIOFF EROR'S CERTIFICATION: I hereby declare that the contents of this cansrgnrcent are fully and accurately described above by the proper shipping name.and are chested.Packaged. <br /> maie,0 and labeledfplacarded,and are in aH respects in proper condition tar transport according to applicable international and natford go yerrwnentai regulations If export shipment and I am the Nmar <br /> Exporter,I--.)�rtiy thal the contents of this cofl4nment.conform to the terms of the attached EFIA Acarrow"rrient of Consent <br /> w0y that the waste minimlutton statement xlenpfied in 40 CFR 252.37(a){d I am a large quantity generator)or(b)M I arn-aAnall quant4y generator)is true. <br /> Generatoea'Offerars PnnWiT ped Name Signature . Month Day Y6ar <br /> ;: <br /> _jl'6 Infernationa]Shipments l <br /> F L1mport to U.S. ❑Export from U.S Port of entryleyit <br /> Transporter signature{for exports only] Date leaving U.S.. <br /> W I Transporter Acknowledgment of Reo�ipt o€Mawpals <br /> 1-- Trar;spor'llar 1 Pnnted-Typed Name Sgn re Month Day Year <br /> Q f <br /> MTransporter 2 Prfnte6Typed Name 5ignawre' Month Day Year <br /> t- <br /> 18.Discrepancy {{ <br /> 18a.Discrepancy Indicatidn Space ❑ Quantity ❑Type LJ Residue ❑Partial R�ecban ❑Full Rejection <br /> Manifesi Reference Number. <br /> 18b.Alternate Faality for Generator} U S.EPA ID Number <br /> :3 <br /> U <br /> rat Faalrty's Phone: <br /> W Ik.Signature of Alternate Fadirty(orGerwaW) Month Day Y.ar <br /> a <br /> x <br /> 19 Hazardous Waste Report Managemenl Metf od Codes(i.e codes forhazardoits waste treatment,disposal.and recycling systems) Notice: state Of California requires <br /> 0 1 2. s generator to phOtocOPy and mail to <br /> DT-SC With 30 days: <br /> 20,Designated Facility Owner or Operator.Certification of receipt of hazardous maleriais covered by the manifest.exoep€as noted in Item 18a BOX 4�Q <br /> Printed,Typed Name Signature 11 Sacramento <br /> .CA 95812-04OD <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL LVr-i <br />