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l:o.25505 I a <br /> ��a pePa��e <br /> d. <br /> OMB No.2050-0039 <br /> Form Approve I ire Na�avao <br /> lease print or type. 4.Manifest racking Number j J K �reaG1� <br /> UNIFORM HAZARDOUS I.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 02 <br /> G 963,488 <br /> � �apa5 <br /> WASTE MANIFEST L 0"31 S07 1 a6& 12.r��� es da <br /> 5.Generator's Name and Mailing Address Address <br /> address) �eQO� <br /> Generator's Site Addre eTnt tha:ng <br /> SON <br /> 'f'iil ORPM <br /> Pr�du�t; I►t�Mini( {, <br /> h�d�n 14 4VVik Sfn�lden,'[A 9��3 <br /> Generator's Phone: 7 3 7 <br /> U.S.EPA ID Numba 7 �� <br /> CA lD NUM <br /> 6.Transporter 1 Company ame U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPAID Number <br /> I <br /> B.Designated Facility Name and Site Address <br /> CM2bY k Ufttlo+1 <br /> 163O W 17th St <br /> Lwm t,CA 9M 3 11.Total 12.Unit 13.Waste Codes <br /> Z Facility's PHSne: 10.Containers puantity Wt.Nol. <br />\a ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No Type <br /> HM and Packing Group(rf any)) �8 <br /> 1. Rq.WX77JftMd9"wad 1^"j.@onzen7 <br /> e)t 9,PC IN <br /> 4 11 <br /> y Z 2 <br /> L <br /> L 3. <br />\ 1;.Special Handling Ins Wctions andAddtional Info motion �jp <br /> 1 IVa.-D22sS � tia�dll^'SS l ($K3�4nt� tie <br /> . srrf <br /> w <br />�y <br /> respects;in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> C+� 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 p P <br /> Expo ter,I ce t fy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. Month Day Year <br /> O= I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity general r)Signaturre or(b)(ill/am a small quantity generator)is true. <br /> GeneratoeslOfferors Printedffyped Name <br /> k` <br /> ❑Export from U.S. Port of entrylexit: <br />�Qz 16.International Shipments Import to U.S. Date leaving U.S.: <br /> Transporter signature(for exports only): <br /> 17.Tanspo[erAcknowledgmentof Receipt ofMaterials Signature Month Day Year <br /> 1011 <br /> C Tans orter 1 Printedffyped Name `' <br /> D {�a�.fR� s�� Month Day Year <br /> L Signature <br /> >_ Transporter 2 PnrltedlTyped Name <br /> 2 <br /> C <br /> � 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.Altemale Facility(or Generator) U.S.EPA ID Number <br /> J <br /> P Facility's Phone: <br /> 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste tr tinent,disposal,and re-cy l4ij�systems) <br /> 1. 2. x' 3:.' ► 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials co bjt ihanifesl except as noted in Item 18a <br /> Printedffyped Name r- Signature Month Day Year <br /> A Form 87]0-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />