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Please prMl or type.(Farm designed la use on etre(12-pitch)lypevrttter.l Form Approved.MI5 No.20K-0033 <br /> UNIFORM HAZARDOUS 1.3erwrat r ID NuM d 2 Page 1 d 3 Ern"em Response Phone 4.WndW Trac►lnq NumbM Q ry �+p <br /> WASTE MANIFEST a U J.: 1 V$ f l7 O F <br /> 5 Gen t rator's Name and Ataynq Address Generators See Address(If Wne ert than maiirq address) <br /> .J (t;lA IML R1 PA114 <br /> ! W <br /> W1W ikkltkWAY <br /> 51OCKICiN i:A L6z r'+ <br /> Generators Pt+ona- <br /> 6.Transporter 1 CempanY Name U.S.EPA 10 Nunmer <br /> 1ASLHIGAA•4 YAL l F Y WA:.I I t art- Ilmx, <br /> 7 Transporter 2 Cam{srq Name U.S.EPA t0 tvtvr�ber <br /> 9.0esignated Fadxy Name and Ste Addrass U.S.EPA 10 Number <br /> V31)! 1.11M.1 <br /> 1'UKIA,A7 It%313:s <br /> FaaF a ptorw���:g�.4 1.., <br /> ga. 9b.U..S.DOT Oesarybant(vd)dril Proper ShQM Name.Hazard Tom.10 Wvnber. 10.Containers 11 Tow 12.Unit I3.Waste Codes <br /> HM and Padit C-Wr 11")) No. Type OLantity W1 AN <br /> Cr. 1 ie4tR(;RAfWAftL)rA).>V4A 1F :;-All) n trA.{ 'I•+ r. <br /> d�idgt EiEtlT 4i.PAPER JN f R ILPN X L A14W. -- <br /> i 2 <br /> w <br /> 3 <br /> 1 <br /> 14.SPecW Har.lirg I hobos and AdddxW Ndolmallarl <br /> t'H�al•ELlJIt1332YNRti I'APLkFILILk:; Lk4AIiI <br /> tA1 lYrSFsWY'(`i NFAt,I i;A;.VR3 <br /> 15. GETIERATOR'S(OFFEROR'S CERTW"Tx1N:I hereby deride oat the coraett6 of this da>bgmwm are fuly and aaxrrateh described above t)y the Proper slvPPr'a tame and are dassfed.Packaged. <br /> naked and labeledvacvjed,aid are mal respom in proper eanoar ldr trseporl woor&mg 10 oprkahle irkmeb°nal and mtmnai go"ertv voW regrdabons II eytat sivpmem and I am eta Prunay <br /> Expdrtr,I urVF(tha the alfnleNs d di5 oolKigfwnerrl cmbrm 10 71e lerrna d fb almched EPA d GQ415e'r!t <br /> i earth oat s+e waste n+rmn plawrrwnt idmttied it l6 CFR 2622T1a)fa I am a forgo 4uanaY generolnrl or rod lxl am a smaA gua:Vh generator)s thin. <br /> Geoeralcrs+prterors Prkdadlryped Name signer" more, Day Year <br /> 16 Mtamatlnna Sn¢vrenls ❑lmpori to U S. ❑Esponkm U.S Pon of erlyaril. _ .-- <br /> � Transporter skpmatura(for erooMorayl: Daleleavtig U.S.. <br /> ¢ 17.Transporter Athgw'ed9<+>arA or Reow of Matmds Month Day Year <br /> Tia goner t Pr te yped Name -- <br /> t�i <br /> zTransporter 2 Prmtedlfyped Name- Square Month Cay Ynr <br /> ¢ <br /> F- <br /> }I 1B.dxsePatCy <br /> 18a.QdaeDax-Y kdc -Spa. ❑O XY ❑T,e ❑Ree due ❑Partial R'alemut ❑Ful Regec4m <br /> Manrkst Releence Nwtw <br /> 16b Anemala Fadify to Gerw,afit) U.S.EPA 10 tEurrta <br /> J <br /> V <br /> Fadq's Prone, <br /> w Sec Sande dAIlerrtate FadaS•lar Gerw�(I Month Day Yea <br /> C <br /> vtl—i 19 Hazardws Waste Report Managertwra Mebod Codes li,e,.codes for hazw tow waste Treatment rbspotal.and recyd'ry t9dm) <br /> G t 2. 4 <br /> Notice'State of Cahiornia requires <br /> generator to photocopy and maul to OTSC <br /> 20. Fadpyowrwraoperator CeAftwmdrKWofmardotaMallna+so0madbYtlwMar4asle+reptasnoted 4nem18a within 30 days: <br /> rind trate b P.0 Box 400,Sacram tnto,C.A 95812-0400 <br /> EPA Form 870022(Rev.3-051 Prtrems editims are ohsdele. <br /> 1 'GENERATOR'S INITIAL COPY <br /> �a. <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />