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Please pdnt or e.(Form designed for use on elite(12-p16:1 typevrtiten) Form Approved.OMB No.2050-0039 <br /> UGenerators <br /> M HAZARDOUS i.Gerremfor ID Number - - 2.Page 1 of 3 Emergency Res <br /> rg q pone Phone 4.Manifest Tracking Number <br /> E MANIFEST C: A R 0 0 0 2 2 5 5 5 7 1 MC.510•:4.1190 �_ �,3����y JJK <br /> S. Name aro MailingAddress <br /> Y f Fi I t 3HT GeneratorsSiteAddress(domemntman mairmgaddress) <br /> 19:�E PESCA SE O NvE <br /> ?CxA.C`{t':rts C463ikJ <br /> Generators Phone: fi. 4 9 -6 i . 1 517 0 <br /> 6. <br /> Trans <br /> N; <br /> Conpan Name- <br /> EN <br /> ame U.S.EPA ID Number <br /> h tvENViR0N6.IENTALSEPIVICES. IigC. C A R ;b 0 a <br /> O 3 J `! i 'J <br /> 7.Transporter Compaq Name <br /> ' U.S.FPAIO Number <br /> 8.Designated nearly��aamma and SpeAddress <br /> i-rusby E%87,01ton,Inc. U,S.EPA ID Number <br /> 151A VV. 171h StrG4e <br /> L. <br /> .F J9e'ach uA 9081; <br /> Facil/s Phon: 562 432-11445 C A C () .y a 4 0 9 0 1. ;=d <br /> go. 9b.U.S.DOT Description(Including ProperShippmg Name,HazmdCless,ID Number, 10.Containers 11.Total 12 UNt <br /> HM and Packing Greup(dany)) No. Type it.Total <br /> 12.Unit 13.Waste Codes <br /> 1. Ro-U0J 1710.Vt4AMM CA.USTJC AL ttiALI L10LJIL7�f,N.O.S.,?,1t. ,.... <br /> I. <br /> O ('r"r+ OKAM HVIDP S`.4fOG BASSO kAnP/ACK) '� ta? <br /> w 2• NVPd-Ft1?AkJ1 irtifh?ii5t!Asm `.OLID,(2r8B ops1Atr,-VMTH <br /> LATV MIN, 3i1 <br /> � S <br /> 3. PJi7WIRCRA f Irv7111'•21J(US MSTE,I,100to.4( IL) <br /> 4. Pi+.)M-J;Z Sj : -- LO, ,dhJ a('ITftii ' <br /> A•.105'1 )n 13^ <br /> li <br /> 14.Sop ��' <br /> dli sWc�(odditonal lnformtlon <br /> �s��d�''I� <br /> �c•�.. 1u1:a�;{ <br /> P �,['.%Tvtr MPL: €r7rcrt,> 9d3�: 51544 902Sam 954t•. 5",126 .. <br /> 16. GENERATOR'SIUFFEROR'SCERTIFICATION:I hwebydedam thatthe contents of this consignment am My end accurately described above by the pmpershlpping rams,andora ciassified,packaged. <br /> marked and Iabeledrplacarded,and ari l!respects in proper condilon fortrenepodsccording to applicable intamationiand national governmental regulations.nazportshipmentand I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tons ofthe attached EPAAdmaMedgment of Consent. <br /> I certify that the waste minimization statement Idenftied In 40 CFR 26227(a)(d l am a large quantity generator)or(b)(ifI am a small quantity generator)is hue. <br /> Generators/Offerors PPdntedfryged Name Signature ./ Menlh' [>ejr Y; <br /> -r 16.Intometional Shipments <br /> z . ❑Import to U.S. ❑ExpMWm U.S, Fort ofentry/edt: - <br /> Transporter signature(for exports only); <br /> DatojeaNng U.S.; <br /> 17.TNnspor W AcknoMedgmcot of Rwdpt of Materials <br /> Tm7rtsr neypeame <br /> Signature- <br /> Cl <br /> TranspoMr2 Pdntotl/Typed Name Signature - Mom' Day Year <br /> K <br /> H <br /> T18.Discrepancy <br /> 18a.Discrepanq Indication Space ❑ Quantity ❑Partial Re)e on ❑FWI Re <br /> El ❑Residue Egon <br /> 18b.Atemale Faal Manifes[Referenat Numher. <br /> 8Y(or Generate US.FPA IO Number <br /> J <br /> U <br /> LL Fadityzs Phone: - <br /> w 18e.Signature ofAhemate FaaTiry(or Gene, Q <br /> ' Month Day Year <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(te.,codes for hazardous wassba treatment disposal,and recycling systems) <br /> v 1• 2. 3. 4.- <br /> 120.Designated Facility Owneror Operator:Certification of recut of hazardous materials covered by the mantlestexceptas noted In tam 18s <br /> Primeaflyped Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. - GENERATOR'S INITIAL COPY <br />