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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 Numher <br /> WASTE MANIFESTG C CIQ 11 019703514 JJ K <br /> 5.Generator'same aDd aili Address Generator's Site Address(if different than mailing address) <br /> Loupl-' 'S�►� loco CO11 2d. <br /> o <br /> mgl g (sail 2ba-,23ti 9 p, c.q 9S?31 <br /> Generator's PhoRe: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Pa 4.-to�l' Err4Vbnm -Y-1 I )&YVA'Gd3 I C A O S33 b b -:H`f <br /> 7.Transp er 2 Company Name U.S.EPA ID Number a <br /> �� f% <br /> 8.Dps d F`a�cikt� arOr�nd ass U.S.EPA Nu be <br /> `0b30b nW�1 t4h S-hYu:tt <br /> Facility`s�P1ho :" c)v1r CA 91913 C C;L2"109019 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 3.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WI.Nol. <br /> Non eC9A &uVJVA6 cos+' ltd! �S <br /> C A<bt5or t �„/ i. (� 2 0CJ <br /> L 2.Non avaA Laza IA"S W ash S1,;4 S -P <br /> 3 ' <br /> 4. <br /> 14.Special Handling Instructions and Additional Inf rm'ti n, �� # iota" <br /> S CV3i5 x <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described 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 international and national governmental regulations.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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or()(if I am a small quantity generator)is true. <br /> Generators/Offerors Printee�d�me Ayw ,,nQ�Q' Signature Month Day Year <br /> If I 1 Z 1"rl 11 <br /> _J 1 to ational Shipments I� <br /> F— I__J Importto U. Export from U.S. ort of entrylexit: <br /> 9 Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name Signature Month Day Year <br /> > �_ C T <br /> a ; Z <br /> ZTransporter 2 rint yped Nam Signature Month Day Year <br /> 18.glafrepancy rr ' <br /> 1 iscrepancy Indication Space Quantity >0 Type L 1 Residue Q Partial Rejection ❑Full Rejection <br /> Manifest Reference It, r: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rat Facility's Phone: <br /> ca <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> F <br /> a <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4 <br /> 20.Designat d Facility Owner or Operator:Certification of receipt o hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signatu �Mon�thDay YearEPA Form 8100- (Rev.12-17) Previous editions are obsolete. YSTEM <br />