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Please print or typo. H4 GENERATOR o. 1 UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
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<br />2. Page I of
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<br />3. Emergency Response Phone
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<br />4. Manifest Tracking Number
<br />023295499 JJK
<br />S. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)
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<br />24/7
<br />Ggit2if1/4-ok' '16" I l'I'l (1(°t)-7 ,1---39 1 :13'2:2_ 1
<br />L4,-De , CA...
<br />6. Transporter 1 Company Name U.S. EPA ID Number
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<br />Company hams_ U.SZPA Number
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<br />it Designated Facililyjamo and Site Address U.S. EPA ID Number
<br />46 0 kf -42--1--o ,--A
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<br />IQ 6, "F>-z,-vkcAik- ., e..A.,_ Qo g i.. I orLTV7s9kine. •-..,2-- 4-f --2- - -.44-ii 9' S.- I( -"') 6.-Y2-2) 09 0 I Cit
<br />ga Oh. U.S. JOT Description (including Proper Shipping Nam Hazard Class, ID Number. 10. Containers 11. Total 12. Unit
<br />PM and Packing Group (If any)) No. Type Quantity WtNol. 13. Waste Codes
<br />- Pc-a-v.4 1-114-2.0p4,-o 1.-( 0,4., i:::
<br />1 50 G rat a-,Sia_. i C.31 L 1 l..4.9eiWR- -Nikk
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<br />14. Special Handling Instruction nd Additional fonention E12_6:,, r.00 fr- /04 Vfal-41 t...4......
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<br />k4)1440• 1-44,44-1 L.- i /-3.6_,- _ ---to f- Lto• B. 5ic1.+9
<br />15. GENERATORISIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ant are classified, packaged,
<br />marked and labeled/placarded, and are in all respects In proper condition for transport according to applicable International and national governmental regulations. P export shipment arid I sin 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 282 27(a) (ill am a large quantity generator) or (h) (ill am a small quantity generator) Is true.
<br />Generaloes/Off l's Printed/Typed Name otki e:34.----- Signaller Me nth I lay Year
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<br />16. International Shipments Import to U.S. 1 from U.S. Port of entry/exit: .1Export _ ..
<br />Transporter signature (for exports only): Dale leaving U.S.:
<br />17. Transporter Acknowledgment of Receipt of Materials
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<br />Traasperr 1 Printed/Typed rune Signature Month Day Year
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<br />14 _
<br />T • er 2 P led/ r Day Year
<br />keg_ IA 0 Litt. 6,02-- - IM I 4--- DESIGNATED FACILITY -4- 18. Discrepancy
<br />Discrepancy Indication Space 11111 Quantity ID Type EI Residue Li Partial Rejection El Full Rejection
<br />Manifest Reference Number:
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: I
<br />Signature of Alternate Facility (nr Generator) Month Day Year
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<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
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<br />7tf/-55-----
<br />7
<br />79/1/
<br />3. 4.
<br />20. Designated Facility Owner or Op a Cerlifica ion of receip of hazardous materials covered by time manifest except as nded In Item 18a
<br />PrinIculf.,,, Nemo. Month Day Year
<br />ell*-41--'"--1-------- 11 ra- kt I F I
<br />EPA Form 82Rov. 12-17) Previous editions are obsolete. - DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM
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