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0 <br />Plem pont or type iFam obSioned for use on elite F72.N1 thl wr,e Atr i <br />0 <br />Form Approves. OMB No. 2050-0039 <br />? UNIFORM HAZARDOUS 1. Cenerabr ID Number 2. Pape 1 of 3. Emegeay ReWmw PU 4. WnRM[Cneldnp m dols, <br />WASTE YAIfIFEST C• •N7 yUli 42{ 5311UL7lEMTREt: �,1 H 2 8 JJ K <br />5. Gawaards Kane and Mailing Address c` ;} D <br />Gerre Ws SiteAedfMs In abandon Nan dealing address) <br />MrViCM 8 BMJA(.•l91 C/1F.VRCJN <br />111,116 F MARC" 1AW <br />SIi7CaKION. CA O521U <br />Generators P <br />6. Tiarvotter 1 Company U.S. Number <br />f'f<I'.M:1(1W f:Wft(jNME3•f[AL SFRVK;Eb MX: Plwanr sa aA1-tidU-;d14 (.AiitNAi1/141: <br />7, Trensperrer 3 Company Name U.S. E ID Nurroer <br />21 it G[-4411URY E)A[[RC"A W,*.NTAL MAWIF.AIFN1 %YF NE VAri t I.L C '= AROCB.I Ili i <br />8. Designated Faeify Name and SileAdAaea U.S. EPA ID Number <br />21 S f GE:1fiURY LAV <br />2CfEl t*WA C 5' nftlVF., FAST iNr yl. 0401 u4tIV <br />FERNt.", NV "408 <br />Facihlys Phone: 17vi-57S 77RO <br />ga. <br />9b. U.S. DOT Description (nducng Proper Shielding Nome, Huard Oise, ID Mishear, <br />10. COraeeure <br />Tdel <br />12. <br />HM <br />WPacking Group Of any)) <br />Qua. <br />GuenBry <br />WLNoI. <br />i. <br />13. Waste Cadee <br />N <br />Type <br />1 fWXV RCRA H UNdoua Wassae P3oYd (C*N [Mwls) <br />rim <br />�• 51 <br />2 <br />3. <br />A. <br />14. Spedm Harming Irem,cbona aid Additional Information <br />ttpaaars io Iss+ 4U18' U eattJ and usr PPF <br />wfl:wl8b•UU / �`r� ERi3Y 171 <br />I8. GENERATOR'SIOFFERORS CERTIRCATION: I hereby de iae that the contacts of this consgenenr are Nay and aCCUMAD y described above by the proper shipping name, and are classified, packaged, <br />mated and labeled'placarded and she in all respects in proper Condition for transport according to applicable Mernaaonal and national pOverrimenta regulallons. If expod shipment and I am 9* Primary <br />EVOrmi, I ON* Nal tie contents Of this ConNgrii COnlomk fo the Imesof the attached EPAActrwdedgnMnt of Coneam. <br />I ad6y that tie Wean mttnvebon emlemem itlen"W In 40 CFR 262.27(x) V l am a largo quantity gMaasor) or (b) (sl am a small quantity generabr) is his <br />G4nmabrslOAaors PwaiCyped Name SWNne Month Dy Year <br />16. mairrudonal keno <br />❑ ImpM ❑ <br />b US F_xoohtlran U.S. Port of entry/esd: -- <br />Transporter signature (for exports only): Dare leaving US: <br />17. Trm*ppter Ackno le0gm td Recapso(MBWeb <br />Twelo der t Phime&Typed Nemo Sionature MOO Day Yea <br />' I <br />• <br />,Year <br />7j <br />wnsporler2 nn ypM None - SgnaN2 Month Day <br />18. Discrepancy <br />i <br />I� 18a' Discrepancy Irgke6on Space ❑ Quality❑Type _� Res'Cue Partial Rejection Full Rajaclion <br />I] <br />18b. AHeaele Fadtry (a Generabr) Me fesl Reference Nx Oen. <br />] <br />tS <br />U S. EPA ID Number <br />$ <br />FeaMy's Phare: <br />16c. Squib" ofAlbmate (orcwwridi Monty Dey Year <br />119, <br />Hazardous waste ReportManagement MAW Codes (i.e.. codes forhuerdae wea <br />waste btrnent disposal, and recyncinp ayslems) <br />1 <br />3, <br />4 <br />1 <br />—.J, <br />SO Designated Facility Owner Or OPOMIOh Certification of recap of hazardous materials covered by she idwas l swat a noted h Item 18a <br />Flifin tum ser <br />EPAForm <br />R7M92IRav'U)AI Prawrwra .r6elnne a.o ,v,e.,rer. <br />