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Please print or type. Farm des' ned for use on elito(12-pitch pewriter) Form Approved.GM6 No,2050.0035 <br /> UNIFORM HAZARIDOUS 1•Generator ID Number 2 P9ge 1 of 3 Mergenty Response Phore 4,Manifest Track Ing Number �/23 �r <br /> WASTE MANIFEST i:dts;.i } �i9 tR�7 <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> :�,?i�rr'.`. w'�.t)�efi i"iia�.l.r''1� flf� Yl- i,�� �'b�.�'%1)"'t•!,ice!"^ <br /> GeneraW51"hone: <br /> $. `"F <br /> ';:'f T "pr 1 Compagypome U.S.EPA ID Number <br /> .TYit{t{1(} {)rr s <br /> 7.Trartsporfar 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Addrese �T ^ U.S-EP V <br /> % - Th3 UADNumber <br /> SACRAMENTO A, 75014i r'3 <br /> a• y,qn <br /> Pada s Phow: <br /> ga 9b.U.S.DOT Oescripdon(Inducting Proper Shipping Name,Hazard Class,ID Number, 10.Contafnars 11.Tptaf 12,Unit i3.Waste Codes <br /> HM and Packing Group(if any)) <br /> No.. Type Quantity Wt MI, <br /> 1-�JA3ra'. JY,TNi AT ED riA71r:.F,,1.Al�- aJi UP-I <br /> a 2. <br /> uu. <br /> ca , <br /> 3, <br /> 4. <br /> 4.Special dandling tnsifucli0n5 and Additional lnformalion <br /> IS. GENERATAR'SfOFFERORR'S CERTIFICATION; I hereby declare prat the confanhs of this consignment are fully and amnlely described above by the proper shipping name,std are dessiSed,p&Aaged, a <br /> marked and fabeledlplacarded,and are in all respects in proper condition for Ira tuport scicordirlg to applicable iniemationaland nallonal governmental regulations.If export shipment and I am the Primafy <br /> Exporter,I Certify that the tomenta of this consignment cohfnnn to the terms of the 8ttached EPAAcknoMLdgmem of Consent. }` <br /> I certify that the waste minimization statement identified in dD CFR 262.27(a)(if I am a large quantity generator)or(b)(if l am a small quantity generator)is Ince, ). <br /> Generattpes:10feror'sPriniedrl'ypedName 3i nature <br /> { g / 1 ., �Qfllh Day Year <br /> l I fE<.Nsf L7 L, .t�, A' �1•�+Pb .,.' f ,.+s-+r�+aw �� , AIL <br /> i&,IntemaliamN Shipments <br /> ❑frtport to U.S. ❑Export from U. Pori of amlrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: 1 <br /> 17,TransponetAcknowledgment of Reoeipt of h1atedals <br /> OTri porter l PrintadlTyped Name Signature Month Day Year <br /> EL <br /> r r, t A'�f-f. d.:^5 ,'? yM'.+' rk'r'. "i' ,•; ,.w!r 13 <br /> r <br /> Z Transporter•PrinledrTyped Name Signatitra <br /> Month Day Year <br /> d �.. <br /> 18 Dismpancy <br /> 180.Dizompanty Indication Space ❑quam[ity ❑Type ❑Residue ❑Partial Refection ❑Full Ref ectien <br /> Manifest Reference Number; <br /> i8b.Alternate Fadlily(o:Generator) U.S EPA ID Number j <br /> � I <br /> i Facillty's Phone' <br /> u tljc.Signature of Alternate Fadly(or Generalor) Month Day Year <br /> a <br /> 19.Hazardotis mMa RapW Management Method Codes(i.e..codes fof hazardous wsglb treatment drsposal,and recycling syslbms) <br /> 20 Designated Facility owner or Operator:Car6ficaliDn of receipt of hazardous materials covered by the manifenst except as nded m Item 18a <br /> Pfimedfr afct Name <br /> Ypp ,r ( Sign)/r8 Month Day Year <br /> • .'�Ip/�'t Ff ('°j++.tr �tj"/ t ! ��.R'j#�I tilt''��p�.'/�'�r o- e?� '� � I �ti" �I <br /> 3AForm t37t)D-22fReV.,7,4)51 PfP.Vinnacvierinncaro nhcr+raln r .' ":' ii'•_i �•+,,,, �1.� k <br /> 899-3 LZ0/900d 06Z-1 9L6�9889L6 raej -rSa >=s-WOd3 6� ZL OL,-B -LO <br />