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4„ <br /> ploase print or type.(Farmdesic neo for use on ette(12•piteh)typewriter-) Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS1,Generator ID Number v r 2 page 1 of 3.Emergency Response Phone 4,Manifest^TTrackingNumber <br /> 177 9 <br /> WASTEMANIFEST 1 {!� s <br /> SKS- <br /> 5.Generator"}Name and Mailing Addrggs generators Site Address{ddMerent than mailing address) <br /> T9,9 SALI�tL- <br /> ;•`q '9I'J'+t <br /> Generalefs Phone- 'r+ �c <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter F Company Name U.S.EPA 1D Number <br /> 8.Designated Facility Name and SileAddress S AFE T Y-KUWK MTEIS,IS, T A 000760 U.S,EPA ID Number <br /> 6000 88114 STREET <br /> EACRAt1EWTO CA IF=::,f.32E4 �_At�('tsif)E4f14'i11 <br /> Foolil es Phone: <br /> 93. 9b-U,S.DOT Dasmption(inducing Proper Shipping Name,tiazsrd Class,ID Number, 1C.Containers 11.Total 12.Unit 2.waste Codes <br /> NM and PacKN Group(if any)) Na. Type Quantity M,Nol, <br /> ar X �t'*NE PfaV4Y RCI-A TED r[AT'ERTALr 3s UNI Z6>4 P FOM P"WI <br /> o fits i7:�i� Gk�`?, �) e. 24J..GALCF'00S,r4Q3;D001i <br /> 5 �q• <br /> i 10 <br /> �, �`f -,X71-57 M4x /GAL <br /> 3, <br /> 4. <br /> 14.SpaoialNandiirglnstructjonsomAdditiona110tormalion TRLM08379674 i:43?�00f59 0000370,91M 37Iii VT <br /> J5. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,&d are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in properoondu6on for transport according to applicable intematonal and national govemmenlal regulations,It export shipment and I am the Prmary <br /> Exponer,I certify that the contents of this Consignment Conform to the teams of the attached EPAAdmevrledgment of Consent <br /> t cerbly that Iia Waste minimization statement Identified In 40 CFR 262,27(9)(if I am a large quantity generator)or(b){til am a small qu2pti3ygenerator)is brut. <br /> GeggratprSlOfferors Pri%edllypW Name Signatt ie r� / Month Day Yaar <br /> �} <br /> J 16.International ghipme4t5 LJ Import Import to U.S, I.J Export from U.S. Port 6f entrylexfl: <br /> Transporter signature(for exports only): Dale loaning U.S.: <br /> W 17.TransporterAckwMedgment of Receipt of Materials <br /> Transporter,f P tedlfyped Name Si nauxe Month Day year <br /> .., , <br /> Transporter 2 Prinloollyped nrn- Signature Month Day Year <br /> nY <br /> w <br /> i8.Discrepancy <br /> 12a.Discrepancy Indication Space L1ajantity El Type ❑R¢sdue ❑Part al Re)ecljon ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) US,EPA ID Number <br /> LL. Fadlilya Phone: <br /> L@ TSc.Signature ofAllemateFaclity(Gr Generator) Month Day Year <br /> r <br /> 57 19.hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,d)Spasal,and recycling systems) <br /> d, <br /> 29.Dosignated FarlWy Owner or Operator,Certification of mcaipi of hazardous materiels covered by the manifest except as n in Item 16a .�' <br /> rinlgdrtyoed Name ta, Signature + Month eY Year <br /> P <br /> )) , ` ,v •� If _a � "fww a�w, N ""lam t, �.r v�+ ' <br /> SMA cam, n"ran„ -- <br /> 899-E LZ0I800d 06Z-1 9Z6�9889Z6 OZ^ZZ 0L,-S�-10 <br />