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• SfiL. :iFf �iHIF��l,"i67fs5Eith <br /> Please Tint or type.(Form designed for use on elite 12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator lDNumber Form Approved.OMB No.2060-0039 <br /> CAAUQrC�41�fw;y 2.Pagaltof 3.FmemengvRespo sePJhoep 4.ManifestTracklnNumber <br /> WASTE MANIFEST l �Y.� YC f.] 004794372 S, S <br /> 5.Generators 111 Name and Meiling Address Generalo(s Site Address(Udigerent men mailing addres) K <br /> �laIS;11��UIi <br /> :'.IQ10 F, F_g117 JE' Ave <br /> I—wirgp CA �4i331Z--5?52 <br /> Generalo(a�nPhyonGeo:m V09-8115A-621121 <br /> B.TrO�oFSRforr�erl Y-7'isrn u:.E. IiYSTERIF,, I)VC. U.S.EPAIONumber 1'JCRI�lb�11DL�].Ern;i <br /> 7.Transporter 2 Company Name <br /> U.S.EPA IO Number <br /> B.Designated FeNllty Name and SlleAddrese CLGAN HARBORS BUT-ruNWILLOW, L.LG U.S.EPAIDNumber a <br /> 145N L>LIKERN ROAD <br /> FaH�.•-r��- ask BUTTONWILLOW CA 93ROG <br /> Facll aPhone: CAA98067 276 <br /> ga, tib.U.S.DOT Descdpdon(including ProperShlppirg Name,Hazard Clens,ID Number, 10.Containers <br /> H� end Packdng Greup(Barry)) 11.Total 12.UNI 13.Waste Codes <br /> No. Type Quantity WINaI. <br /> NGhll:, DEB RCRA HAYNRI7L7lJy WASTE �i(7LIIY.as AM P a:iL� <br /> 0 4C1ILY AF;J3RS:1?, N/A <br /> A S� <br /> z z. <br /> w <br /> w <br /> 3. <br /> AP 08 201 <br /> 4 <br /> HCA'TUr)CDAOT4 h1T <br /> V" <br /> 14.Special Handling instructions andAddllbnei lnformallon )":IU:.HL, 66/+5E17h.18 <br /> SCODC #1-61110-468-17 Go <br /> SIU � RIZFTO RETAIN LICENSED fiED SUPMIIENT CARR I - A5 NECESSARY <br /> 15. GENERATOR'810FFEROR'S CERTIFICATION: I herebydodare mal mco <br /> e contents of nsignmenttire(ullyandaccurately described abov6 by the proper shipping name,and are classified,packaged, <br /> marked and lebelediplacarded,and ere In all respects In proper condition for transport according to appliwbte Inlemalionaland national govemmental regulations.if export shipment and I am the Primary <br /> Exporter I certify that the contents of this consignment conform b the terms of the attached EPAAcknowledgmenl of Consent. <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(If I am a large quantity generelor)or(b)afl em a.small quantity,generator)Is Imo. <br /> Genera ran)eroi'a Pdnled?ypad Name, ) Signature Month Day Year <br /> 1q.Internationa ShlpmeAls '.- <br /> ❑import toA. El Export from U.S. Podofenlry/adl: . I <br /> Transporter stgnetme(for exports only): �' Date leaving U.S.: <br /> W 17.TramporterAcknoWedgment ofReceiplefMaterials <br /> Tran ported Pdnie yped Name '-"' <br /> a y� / ' SlgnaWre" Monro Day Year <br /> T sporter2Pdn Ifyped Nama ,Y � ?.% Y-+ i <br /> gtrelure Manlh Dey Year <br /> t- <br /> 1 18.Dlscrepency <br /> I 18a.D6crepancylndicalion Space ❑ Quantity ❑T e <br /> YP ❑Residue ❑pertlel ReJedlon ❑Full RaJecUon <br /> Manifest Reference Numher.186.Allemale Facility(wGenerelor) U.S EPA ID Number <br /> J <br /> U <br /> M Fscllllye Phone: <br /> apDospated <br /> Signature ofAlternale Facllily(or Generalor) Month Day Year <br /> CD <br /> Z1. aste Report Management Melhod Codes(i.e.,codes for hezordouswaste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> acility Owner or Operator.Cemscation of motel of hazardous materials corered by me manifest except as noted in Ilam Ise <br /> me Signature Moolh Oay Yoar <br /> EPAj F1o738j��F ylRey4U0 ty,Qr2Syt s edllions are obsolete. GENERATOR'S INITIAL COPY <br />