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Please print or We.(Form designed for use on elKe(12-pitch)tpewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Pa@j 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> '3 7 F, 0) <br /> WASTE MANIFEST C A L A I)Q,?63 4261,-92041 A <br /> S.Generators Name and Mailing Address +2 13 6 JJK <br /> Gener"s SmAddmss fffdffmnt than mang Incomes) <br /> 3327 GLAR!t. 0� <br /> -iAs, <br /> Generators Phone: 1313U-20010 <br /> 6.Transporter l Company Name U.S.EPA ID Number <br /> TAL SE104 <br /> IC A D 11i, 8 2 7 7 0 3 6 Ale <br /> 1.Transporter 2 Company Name U.5.EPAID Number <br /> 8.Designated Facility Name and Site Acidness U.S.EPA ID Number <br /> V. sit <br /> '4tJ,o;2,ij <br /> Facilitys Phone . . - G()1) 1 - <br /> r 0 IS 001 G <br /> 98, 9b.U.S.DOT Descripbon(including Proper Shipping Name,Hazard Class ID Number, 10.commi am 11.Tobi 12.Unit 13.Waste Codes <br /> and POCkolf)13�1)Iff any)) I Type <br /> Quan <br /> HIM Na. tity wt.ml, <br /> rr 1-Ni)f;,-RCRA HAZAAW15q.5 WASTE LlIDUID(ETPYLENE GLX01- 0 1 r I G 133 <br /> 730 <br /> ILI <br /> 2. <br /> CD <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional information <br /> %�# "S, 171 X I--1fKIqLE#Ilt"13 !)K100183 "'w-EMERGEW-Y tYONITACLCHEMTREC 1-800-424-9300 <br /> T •TIiEiTE Ima ARG—p-i+'-ERLMEN <br /> L <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedam that the contents of this consignment are filly and accurately described above by the proper shipping name,and are classified.packaged. <br /> marked and labelediplacanded.and are in all respects in proper candflion for trainspon according to applicable international and national governmental regulations.If export shipment and I am the Pinmary <br /> Exporter.I certify,DW the contents of this consignment conform to the tans of the attached EFAAcknowfedgment of Consent <br /> I cardi,that Be waste minimization stat5mentIdern86ed in 40 CFR 262.27(a)(ff I am a large quantity generatur)z(b)(it I am a�11 quantity generator)is true, <br /> M GeneratueslOfferces Hawly"ed Na Signs MRM—DayYw <br /> Is.Internanonal Shipments <br /> El pd to U.S. LJ Expod fman U.S. Portafentry/exit <br /> Transporter signature(for exports only): Date hearing U.S.: <br /> 17.Transporter AcknowAAment of Receipt of Matemis <br /> —13Q$RMs,k 1 Plinted/Typed Name Sgnew <br /> 0 t f Month Day Year <br /> Tca er 2 Pnn ypad Name SignIftill Morn <br /> Day .than <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spew El Quantity El Type Elpesidue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number. <br /> U.S.EPA ID Number <br /> LL Paoli"Phone <br /> W 18c.Signabre O'Nsernam Facility(or Generator) Month Day Year <br /> z <br /> 19.Huandous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling system) <br /> 7.— 2. 3. <br /> 1 20.Designated Facrkry Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as ndedirilternl8a <br /> PdntedfTyaedName <br /> Signature Month Day Year <br /> .PA Fon 876022—(Rev.j-ub) Previous eCrifions;are obsolete. <br /> DESfGNIATED FACILITY TO GENERATOR <br />