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z r � <br />view print or type. roan aesigneo <br />Tor use on aura iz-pta n ewntec) Foran Approved. OMB No. 2060.0038 <br />UNIFORM HAZARDOUS <br />I' . Generator ID Number <br />CALi <br />�2. Page 1 of <br />3. Emergency Response Phone <br />iA-.V I ' <br />4, Manifest Tracking Number <br />017145320 <br />WASTE MANIFEST <br />a3&S°.f!@ <br />-VI <br />J JK . <br />5, Generator's Name and Mailing Address Generators Site Address (Ir different than mailing address) <br />law INVUS11RIAL QR <br />STQf.XTrk1, C.A. <br />Generator's - ++ <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />era <br />PArMTS Mvf. ;. :JITAL SMXEa SIC. i.AQD4 -6 <br />7. Transporter 2' Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Addressp U.S. EPA ID Number <br />(� C <br />I�.�wl1L7'+7 J`.YI{�Vt'N11GilTM 'Tim{�Y17�G'�7 +MIb.. <br />1+3111 SfrttTf'4�tR f,SQ. C!t!''0.4•��?�a <br />WEST SpkCRAlaiE°Ad%D. Cis WM$ <br />&" <br />Faclill es Ptpnei$1 <br />OL <br />& U,S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, <br />10. Contalnem <br />11. Total <br />1Z Ufa <br />13. waste Codes <br />No. <br />Type <br />.HM <br />end Pacldng Group (Ifany)) <br />tib <br />W Ahl. <br />1. Aires RCieA WZARO-Aia WP,4'"% a tti ((IL, Demi) <br />0011 <br />0161 <br />!+ <br />t 14 <br />2. <br />=: <br />44 Special Handling Inabuctlons and Additional Information- <br />Q�11F�t�f€if.1tiT4F <br />Ila COMTRACTICIP" RAWJ—S A"� <br />15. GENERATOR'SMFFEROR'S CERTIFICAnON: 1 hereby declare that the conlsMs of this oonslgrawt are fully and accurately described above by the Propersbfpping creme, and are dasel fled, paskr 44' <br />marked and labeled/placarded, and are In all respects in proper condition for transport according to applicable International and national governmental regulations. If export shipment and I am the Prlmary- <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br />I certify that the waste minimization statement Identified in 40 CFR 262.27(x) (if I am a large quantity generator) or (b) ('dl am a small quantity, generator) Is true. <br />Goversla'00 ors PdntedfTyped Name Signature Month 'Day <br />F <br />Intertmatbaal Shipments <br />•. ❑ Import to U.S. ❑ Export from U.S. Port ofentry/exit <br />Z <br />: Transporter signal (for exports only): Date leaving U.S.: <br />17. Tra sportarAcknowledgment of Receipt of Materials <br />Transporter) Pdntedfr arnej SOW!" Month Dry ruler <br />CL. <br />Transporter 2 Pdnlad/Typed Name r5imature MorrBm Yew . <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ quart ty ❑Type ❑Residue ❑ partial Re)eation LJ Frltliajedlon' . <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />V <br />4 <br />1U. <br />Facity's Picone: <br />LC3 <br />1 ft- Signature of Alternate Facility (or Generator) <br />Month Day . Yew <br />19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systema) <br />G <br />1, <br />2. <br />3. - <br />4 <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br />Pdntedffyped Name Signature Month Day Ybar <br />A Form t5/W-2L (Kev. 4-Uo) t revious eamons are oosorete. umcnAtun'a lima 1INL WP'i <br />