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1 <br /> � ■ I <br /> ForthAwmved.OMS No.2050-0039 <br /> Please print or type.(Form designed for use on elite(121fth)typewriter.) z.Pag tot 3.Eme�e�Y Res Phone 4.Manifest tracking Nrumber <br /> }iAZAR000S <br /> I.•Generator IR Numbew del , f J K I <br /> UNIFORMC A L 0-00 1 3 3 <br /> t WASTE MANIFEST <br /> err`' ilingaddressl <br /> 5.Genaa's ,, GeneratarsSitaAddress(ilcfi;f�rantthanma <br /> rat ' <br /> L---204-A 95240 2091365.0175 <br /> Generatofs Phone: U.S.FPA 10 Number <br /> 8.Transporter 1 comparry Name CA L 000253361 <br /> U.S.EP,y lD Number <br /> 7.Transporter2 Company Name k <br /> i <br /> tai f3 U.S.EPA ro Number <br /> 8_Desconated FaCi6ty Name and Site Address <br /> 1'rr4"�src•=M AIM-- <br /> rr3+r�i 3..i-u�G {':.dy fi�iJJ �r�1�V'T1�e3 <br /> Faclays <br /> ga 96.U.S.DOT Descrlptlan(inducfin9 Proper Shipplrg Name.Hazard Class.IG Number. 10.Containers 11.Total 12.Unfl 13.Waste Cedes <br /> Hht and Paradng OW(if any)) Na. Type Quantity WtNot <br /> t. <br /> w 2. <br /> c� <br /> c. 3 <br /> } <br /> 1 <br /> 4. ; <br /> I <br /> 14.Special Handling lnstructaes andAdaknal InfdmMon <br /> PF' ,'YFS:.Yiff <br /> I <br /> 15. GEti RATOR'SfOFFEROR'S CERTIFICATION:1 hereby dedam 7satthe is wdu of ihls conaigmnent are fuAy end acaua*dasaPoed above by the proper shaping name ata dasslfied,packaged, <br /> iParked aW labeladlplacarded,and are in all respects in properconddiort for hansport according to applicable inm6amationalanbd nafbrei gawwordal regulations.ff atgm ahipmentand I am the Primary <br /> 1 E*Mr•Ice*that }j6rds of this consignment conform to the Deng aF the attadted EPAA adgme <br /> l cergly ftl the u� tion statement lderrtified in 4G CFR 2V 27{a){'d I em a terga quantity generator)or(b)(€I I am a small quahgty gen e. Month Day Year <br /> Generato era yped Name Signature <br /> —19'Wit—mborifShipmenta ❑knpod to U.S. ❑Exporltram .5. Port of ent want <br /> r Data leaving U.S.: <br /> Z Transporter signature{fur exports only): <br /> I <br /> W 17.Transporter Arbv*9d9merd of Receiptof Materials <br /> • � Trarrsportet pdnledriyped Name Slgnalure AIOo Day Year I <br /> sf Monih Day Year <br /> 7 po r2 me ped Name Stgn <br /> i � 5 <br /> 18.Discrepancy <br /> 189,Discrepancy Indication Space ❑ Quantity ❑Typo ❑Reekt oe ❑Par6a1 Re}eWon ❑Fut Rejedion <br /> Manifest Reference Number. <br /> 18b.Altemate Fadlity(or Generator) U.S.EPA Ip Number <br /> :J <br /> U <br /> Facray'sPWe: Mordh pay Year <br /> 18c.Signature of Alternate Facility(cr Generator) <br /> LUz <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes tot hazardous waste treatment d'sposal,and recydirug systema) <br /> c t 2 3. 4 <br /> 14 j <br /> 2G.D Ignated Favi ty Owner or Operator:CeMeation of nate't of hazardous matelots covered by the manifest eikcept as nem 1 Be pay Year <br /> PAntedfryped N"(-' <br /> -� Sri i <br /> EPAFarm 670 22{Rev.3-05) ons ettitions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br />