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' .v'-.,r..�.R ^;;� . :der''°,a,.• <br /> Please prlrll or type,(Form deslg'ritd for use on elite(12 Itch)typewriter.) a Form Approved,OMS No.2050-0039 <br /> OUS 1 r a.Man los rackEng Number <br /> OngJ42 4 9 " o C <br /> WASTE MANIFEST 2 Page i of 3 r ��6poonsse Phone <br /> UNIFORM HAZARD <br /> 04 <br /> 5,G q r , nd ail�d�d►ess Gerutratofs Ste Address(If different than malting addressX <br /> 3%�T(r RK i3kNti <br /> OGeTON. CA.95.205.9231 <br /> Generator's Phone: � $ '� <br /> '12-TIS VFffflfle suvjca Inc "'V9 000 97 .1. <br /> 7.Transposer 2 Company Name U.S.EPA ID Number <br /> F CJI e 11i� �Y1lic ITi(:. "'01060029751 <br /> .'0 ® 07 <br /> Vvoadvifiez W. 64028 eM-241-2004 <br /> Facility's Phone; <br /> ga. 9b-U.S,DOT Description(inducting Proper Shlppiny Name,Hazard Clasa,ID Number, 1o.CcnWners 11.TOW 12,Unit 13.Waste Codes <br /> HM and Padctirg Group(Pf any)) No. Type Quantity W6Nol, <br /> :F <br /> Q. 1 � �La ;fR f'f �Y� fitJ t<.i7,� f ... �� ._. - - - 1 _ f� _ fir: <br /> {3 <br /> LU 2° <br /> w, <br /> This Copy is Yo6r <br /> 3e . <br /> OF RECYCLING � <br /> 14 cial H dlln Ins dans Adan pal Ipftimlet' <br /> ' +tt� h arlhew ar, 9,,1,-C)f G tf ( 11' <br /> 15, GENERATOR'SfOFFEROA'S CERTIFICATION!I hereby dedsre that the wntenfs of thls canalgnmt nt are fully and accurately described above by the proper shipping name,and are classified,passaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport ao=Iing to appllcatde Intemallpnaland national governmental regrdatlons.If export shipment and I am the Primary <br /> Exporter,I:certify that the oonlsnis of this consignment rorforn to the terns of the attached EPAA(*nowledgment of Consent. <br /> I Certify Ihat'Ihe waste minlm>zation'slalomant Identified In 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am Asa alLttµogl)1y generator)ts true. <br /> Generators! ifefor's,PrinfedfryW.N)Me Sign e ; Month Day Year <br /> 4" . ;; <br /> 6. nterna1ronal hipmenle <br /> ❑import to U.S." ❑£xport from U.S. Port of entrylaxit: <br /> Transporter signature(for exports arty): Date Isaving U.S.: ` <br /> LU 17.TraneporterAcknovAe lgmeot of Receipt of Materials <br /> q Tra Router 1 nladrl)"d Name ✓ S oalure •7 Month Day Year <br /> &'A-4 <br /> Transporter 2 Prinledlfyped Nam® S gisafure Month Day Year <br /> 18.Discrepancy <br /> i$a,Discrepancy Indlcatlon Space ❑Partial Rejection ElFNI Reject= <br /> ❑ Quantity ❑'{ype Residue <br /> Manifest Deference Number- <br /> 18b, <br /> umber18b,Ahemate Facillly(or Generator) U.S.FPA ID Number <br /> J <br /> V <br /> uU<- Factlitys Phone: <br /> ow18c.SignatureofAl(emateFacility-(orGeneralor) Month Day Year <br /> s a <br /> 18.Hazardou&.Wasls Report Management Method Codes(I.®,i oodos foe'hazardous walls Ireaunent.disposal,end racycfing ayylems) <br /> LLL1. y 3, 4. <br /> mom <br /> 20,Designated Facility Owner or Operator,Cedif atlon of receipt of hamdous matarisle covered by the manifest qooqt as n Item 14 <br /> Pri waT,* I t fi - Month Day Year <br /> l f° "fir f J <br /> �-� �d <br /> EPA Form 1117110.92(Rev 9461 Prav"tixis MiKom are obsolete. <br /> 'd 9650 '°N ' DEA dl6 X13900 daS « nr <br />