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typewriter) Form Approved.OMB No.2050-0039 <br /> Piease pdnf or type.(Form designed for use on elite(12-pitch) Phoma 4.tlanlfest Trecking Number <br /> 1.Genoretw Id Number 2 Page 1 of 3.Emergency Re&panse 005963205 J J K <br /> 4 UNIFORM HAZARDOUS C A L 0��0 z 9 4 3 0 n � !��� ��'f� <br /> WASTE MANIFEST <br /> 5.Generet0t s Name and fufaling}Address_ s. Generator's SiteAUdress Qf diffanom VW maifug address) <br /> PEP BI-, S <br /> Generabor's Phone: '' U.S.EPA ID Number <br /> 8,Transporter 1 Company NameCAL000 2533151 <br /> U.S.EPA[[]Number <br /> 7.Transporter 2 Company Name <br /> S.Designated Facility Name and She Address U.S.EPA ID Number <br /> r'-f%F"V Ill_}:.��'&-Xf1`i.. w AT 08 00 25 } } <br /> Facilivs Pt9QNTA144,-A rr0W356-9CQ5 <br /> 9a. 9b,U.S.DOT Descrtption[Mcludng Proper Shlpping'Name,Lazard Gass,ID Number, 10.Containers 11.Total 12.UNt 1S.4Vaste Codes <br /> HM and Paddng Group fd any)) No. Type Quantty V&Nd. <br /> 1. <br /> �:'M-T a,iii�`?T ;ii G, 4l .�;' LTQUT-T 0 r O <br /> w <br /> U) <br /> 3 <br /> 4 �. <br /> j 14.Special Handling Instructions aodAdditional Inbnnalion <br /> yn ,zl�s.;,PFY'31'cui 7Y PIF-17NALPR70 F-CmrEEc4iJEPI~dmr <br /> 15" GENERATOR'S16FFEROR'S CER11F1CA-ROM: I hereby dec are that the contents of ih�consignment era Idly and aucurately described above byte proper sh'ppi 0 name,and are classified,packaged, <br /> marked and tabeiedlplacareed,and are iu aft respects In preps condition for transport acwtdIng to applicabie imtematonal and national gmrammartal regulations.If export shipmentand I am the Pdmary <br /> Expwler,I ceitiy that the contents of this consignment oonf0;:-"to the terms of the attached EPAAdonowledgment of Consent. ' <br /> I cerSfy that the waste minimization statement identifred in 40 CFR 282-27(a)(if generator)am a large quantity generator}or(b){fFf am a sme8 quanhy generator)is true. <br /> relorslOHeron sPriv typed Na Signature <br /> GeneMor>fh Day Year <br /> ems' � f 1 � <br /> c ifi.Inle Shipments Import to U.S. <br /> ❑Expart4om U.S. Pon enayloxie <br /> ? Transporter signre(for exports only): Date leaving U.S.: <br /> aru <br /> W 17,TrdrsporterAdmWedgmentofReceipt off+t Wals <br /> Transporter 1 yped Name / signature Month Day Year <br /> r <br /> /� f 7 <br /> Mortis Day Year <br /> Trans 'liter 2 Pdnfe type <br /> a <br /> r <br /> 18.Dlscrepancy <br /> 16&Discrepancy tndicoWn Space ❑ Q.,k ❑Type ❑Residua ❑Partial Rejection ❑Full Rejection <br /> �r <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Geneiator) U.S.EPA ID Number i <br /> V <br /> L6 Facility's Phone: <br /> 0 18c.Signature Attemate Fadlity(or Generator) Month Day Year <br /> a ` <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(Le..colas for hazardous waste treatment,dsposel,and recycrmg systems) <br /> LU 1. <br /> H, I L4 <br /> 20.Design d Facility Omar or Opemtor:Cer futon orreceipt of hazsrdous materiels covered by Iha manifest exceplas in Ram 19 <br /> P' ypedName Signature Month Day Year <br /> EPAFonn870022 ev.3-05) Pre iousedithnsareobsalete. DESIGNA D FA ILITYTO GENERATOR STATE(1F REQUIRED) <br />