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• REC'0 JUL 2'2 2015 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Track Number [+ /'+ p <br /> WASTE MANIFEST r�.tr."•,;);n;s or;rA.)T.4'- U�2139576 GDF <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> IN i tRa;iA'f£ IR%K.K CWT ER <br /> III) i;t7h(34F1 S 9??i f4AyY (R! <br /> t•.)r.?pitIt!.%;A 95206 `KK'KrotI CA 952M <br /> Generators Phone: r)rs. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> :'V';IecRICAN 1tFi.{.C'Y WH:;k"Y,till. RX; U.S. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ..T S':1 r;C-NICItt'Y EN✓I414X1ME:txi/At. M<�Tr4{ ;7{ hiT 4XxC'h,i{r: <br /> Jtfda hS-lNt fiCA Iv UH F.ASi NV{T r)STJ711!?v;i,A„V.. <br /> €Fd:Pdi.i�.V Nv ssl«lin <br /> Facilitys Phone: I r: <br /> ge. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> m 1. f.K-MV-R(:HA!-tA,'F.fi11{r(1;';1.n/Av;SP. '•+I ff):: , 1;.9 !'75 P 223 35= <br /> AH:i:rINYiGp{Y57 A i NI <br /> 2 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> PR 01 11.1.0 100345-ill) Ai11v-4R4Yk1'll A rJll.-t..1 tt3N t 11 <br /> i:CtNTAi:f. fHiN <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iaheledlplacarded,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 Primary <br /> Exporter,I certfy 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 idenUfied in 40 CFR 262.27(a)(U I am a large quantity generator)or(b)(UI am,a small quantity generator)is true. <br /> GeneratorsrOiferors_P)nntecirryped Name Signasure;: / % Month Day Year <br /> j 16.International Shipments <br /> f— <br /> 1-1 Import to U.S. LJ Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/T��jjpme ed NaSignature Month Day Year <br /> ya h Z, YAM +fes 7 / I '11Y <br /> 4 Transporter 2 PrintedrTyped Name Signature Month Day Year <br /> a <br /> I-- <br /> } 18.Discrepancy <br /> fee.Discrepancy Indication Space ❑ quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Faciliys Phone: <br /> w ISc.Signature of Alternate Facility(or Generator) Month Day Year <br />