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Oct. 22. 2012-- 2:46PM No, 1163 P. 3 <br />Please orimtortvoe. IFnrm dnsidnad#nr uco nnelgnyv,wbv ., • <br />RX Funn or uucc(nev. mus) Prevlbus ealuone are obsolete. DESIGNATED FACRilYV TD GENERATOR <br />_ --._..._ ..-..,,_...,_.. . .. FonnA rovad.OMa No. 1050.0039 <br />UNIF HAZARDOUS 1. GwwaNrJD Number 2Pagefd d.Emargency Reaponsephone, 4, ManNasf umbar <br />7hecNing <br />" STE MANIFEST s _.... A 0 8 3 76&.' JJK <br />S. Geri%elcla Ne dMall�g Addrms Generator's SbAddress(idlHmant than maling a..) <br />i•. +,,X' acs sxaS :E ^a YPr.'kf:afcS p'2'P Clack nxiva )A£.ku- lilnuos Qv.vre <br />':';:.!', ?.cab; ave <br />.�d,rer9rT„'rr�, CA 'x;9ki19 .� b:£nr..Y.Y��, i:9 45.2gdi <br />A <br />Genereloes Phone:".. <br />6. TransporWl CMlpanyNema v U.S. EPAIDNUmDer <br />a. <br />r-71 <br />7.TrenepOdar2Company Name U.SEPAIDNumber, ' <br />it, Ut lift. <br />8. D4SIg^alBd FBcimy Neme d' <br />U.S. EPA ID Number <br />P"A. $7YlEC5aJ.L, X.TiC. <br />F'ar#rsr ,Plea. .. ... <br />Fadli mPhcma: q28_;11 .. <br />08, 91d. U.S. DOT DeacripUan(M0W(V Proper Shipping Noma, HamN Glass, ID Number, 10, CQ*inere 11.Tael <br />.. 12. Unit <br />HM and P2cldng Group(itarry)) 1g: Waste Codes <br />No. Type Quaintly NRNaI. <br />1'TIMa-kCi.Soa H�zenxdvus �Ask.e 9alid (PiAy <br />a9 <br />AAa;exllcrlY �.•. lPaNa:aar) <br />� <br />1)0 bOp <br />� <br />SSR <br />K <br />w <br />2. <br />w <br />74' <br />.14, Spedal Handling lMustlohniAddional kg%magon <br />t 15.t'l l2 % �r�' <br />y1'^7QILrx,V <br />iO NO)EI(lmade; Walser Appzapint'v P'Qt*rirr Cl.astlaltr..q ' +c.:. <br />15. CENERATOWSIOFFEROWSCERTIFICATION:- I Mfeby declare that the mntanN of thIs Consignment am fully and ewarately, demented above by the proparSUpping nemB,aNare Cre991lW. packaged. <br />marked and laboledlplacarded, and are in Q respects In pope? ialditlan for transport axofdng 10 appllaNe imematiormland national governmental negulatonc. Rexpommhlpment end i am Uie Pdmary <br />Expo^er, I Cenlfy that me cantanls of this onslgmlcboion to ma [am of the abghed EPAAcknowladgmentof Consent, <br />I CeNIfymM me waste minimization statement idemified in 40 CFR 262.27(a)(d l am a large Quin* generate) or ism me 11 quanllry ganorator) is Wa. <br />Gary am eroYsPdnt Name Signamre t 4 _ Month Cay Year <br />re- M-5 <br />T /D <br />r <br />1b. 1^1emelbme1 Shipments Import to- <br />US. - - <br />❑Expahlom <br />z <br />— <br />US. Pat of <br />Transporter signalers (For sepals Dow: , Date WAng US.: <br />w <br />1T TransporterACknoWilogreanl of ReceipldMaeriale <br />Transporter l PnrJwt Typed N $NnaNfe Mcnm Day Year <br />$arm <br />," <br />a <br />z <br />x <br />Iraneporter2 P Typed Name - Si aNre <br />gn - 'Morm Day. Year <br />H <br />tae. Diwepancy lndcallon Space ❑ taw,gty ❑Typo ❑RIO,.. ❑pima Releotbn El <br />Full Relecton <br />banlMmt Reference Numbac <br />i8b. Alternate Facility (%General%) U.S. EPA ID Number <br />U <br />w <br />Fadiily's Phoria <br />i8c. Signature of Alternate Faclllry(or Generator) Day ; 1§er <br />Q <br />z <br />y19. <br />HazafdeUeWage Report Management MalhM Codes (Lay. odea fm hsrardous waste 4eatment, disposal, and recycling systems) <br />p <br />1. <br />2. <br />3, <br />4. <br />2a.Deslgnaled Facility Ovmer%Oper&r.UrkncationoimcerytofhappNommaledalsmomd nvnifestexopteendedlnl(emi0a <br />Hniedrlyped Name sigimNre. Manch^. Day Yew <br />RX Funn or uucc(nev. mus) Prevlbus ealuone are obsolete. DESIGNATED FACRilYV TD GENERATOR <br />