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05/26/2010 15:37 2097270859 <br />• <br />Please print or gtpe. (Form designed for use on elite (12 -pitch) lypewrifer.) <br />GEORGE'S #0885 P,002 /002 <br />• FonnApproved. OMB No. 2050-0039 <br />GPA Form arw-a (Rev. rup) Previous editions are ODSOple. <br />GENERATOR'S INMAL COPY <br />NW -ORM HAZARDOUS 1 1. Gumemaa 10 Numder <br />2. Page 1 of <br />3. Emergency Rcspar. Phone <br />4. Manifest Tnii&ing Number <br />G B F <br />WASTE MANIFEST i:Ai i j.XZKt <br />i <br />>»T 'F.;' Jte <br />S. Generai Name and Mailing Address Gimmlols Site Address in drMeremthen msiting address) <br />GE00-1i`IS, W4. WT <br />(Yi-r--zF0P , CA, <br />Generators Phane:;f' ;.1•Sh."�', <br />B. TwupaAv l Carnpanr Name U.S. EPA ID Number <br />S64.1ili I AZAf QrS 7;0Lj13TKtili, A lt6sbPaEdB! <br />7. Transporter 2 Company Name U.S. EPA ID Ntenber <br />8. Designated Fadity Name and Site Address U.S. EPA ID Numyer <br />614111lf'1�}�'R: it' <br />Mwill <br />R.1'S3��ttr3 C'?SiLdiV'lY, i;'.A S(+',i'e <br />Fadlil Phone: $i&�51-1=�r;�'s <br />go. <br />9b. US. DOT DescrWorn (Inckxfing Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Tofal <br />12. Unit <br />HM <br />and Packing Gralp(dany)) <br />Quantity <br />Wt/yd. <br />13. Wasp Coders <br />No, <br />Type <br />7. ltS�t'C?..rL aisiRSf JfJ13f.1.:F:,3.J., . i <br />' z <br />Et <br />? <br />: <br />P <br />of <br />X13'. <br />'FC1vc+ <br />z <br />2. <br />7 <br />3. <br />4. <br />1 <br />14, Sprawl Handling Instructions and Additional Inforntetion <br />3'F'+Jrtli �'ae?,9?aJ�"Ls). csgf�lk�:-€t �+1h�' i-iL 6ERU� rbJ�b 8 <ittva A .�C)�kTa <br />?>,i'f'Nt1f"faFTc i'Cit_'Tc'.; YiS'C 4'i.0ir3PiCi <br />SEE tR � �i 1f <br />15. GENERATOR&OFFEROR'S CERTIFICATION: I hereby declare Nat the ocrilenb: pfihis coraigratedarefury and acplydtelydesanbed above by tlp propershipping nom, and are classified, packaged, <br />marked and Wbeladlplarardad, and are in all respects in properrondropn for transport according to applicable national governmental regulations. If export shlprent and am the Primary <br />Exporter,Ioefbfl'totthe contggy ofthiy congkpunent conform to the term ofthe attached EFAAck lulgment of Consent <br />I oerlily ltptthe wasp mir im'padm s=ement idwa5Bd m 4/1 CFR 28227(a) (rf I am a large q"tG generator) or (b) Cdl am a smd quamhygenerafor) issue. <br />GeneramtNOBaroes PmM1eNfyped Name Signount Mash Day Year <br />- <br />.) i-` �- <br />54 . . e- <br />r— <br />Z <br />16. international SNpmenls✓ .. <br />❑Impot ro U.S. ❑Expel from U.S. PortofenbylsA <br />TrAnsporwmgrs Ifor expom only): Dep leaving U.S.:' <br />w <br />17. TranspORefAdoirovadgmentofReceipt of Materials <br />2 <br />Transporter l ftepri!<yped Nartp Signature Month Day Year <br />a <br />w <br />t 1I � <br />Z <br />Trerspofpt2 Prraedll Sg pay Y <br />K <br />f <br />18 Discrepancy <br />Ise- D'waporxyIndirdinn Spam ❑ Quagupy 1:1 Type UResidue Portal Rejection ❑ Fu0 Rejection <br />Nuvviww Reference Number. <br />78B.P11EmNte Fadiry(orGercvaMr) U.S. EPA iD Number <br />J <br />V <br />Fad" Phone: <br />w <br />18c Signature ofAaenpp Fsdky(or Gereremr) Mmlb Day Year <br />Z <br />I <br />M19. <br />Hazardous Waste Report Managemerrt Met rod Codes (i.e.. codes 4o haardouswasm assonant dispceal, and 2eycstg sysler�) <br />3. Notice: New federal form. State of <br />California requires generator to photocopy <br />20. Deskgreted Faafny Qomr oroperato: CeAfipt'on d recsipt of razartwus m Wit s wvsred by 8u manilcst except as nolod in Item Ise and rnail to D'I'SC within 30 days= <br />P"gftdj%ced Now Si9^et ^e P.O. Box 400, Sacramento, CA 95812-0400 <br />GPA Form arw-a (Rev. rup) Previous editions are ODSOple. <br />GENERATOR'S INMAL COPY <br />