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j <br /> base print or type.(Form designed for use on elite(t2-pitch).typewriter.). + ' Form Approved.OMS t1o.2050-0089 <br /> UNIFORM HAZARDOUS ;1;Generator ID Numbers_ : '- 1 2.Page`1 of 3 Emergency Response Phone 4,Mani[est Tracking NumtJer <br /> + WASTE MANIFEST � u',' - �. <br /> 909-8ss- 7 -0002:59`7 5 JFK <br /> ! :• 5.Generators Name and Mailing Address ' Generator's Site Address{if different than mailing address), <br /> f Utdited WesWm GOCef 8 <br /> hi _ 9 G: <br /> Atn:Pet C .:... <br /> ilty.5200 Sl�si�Street . _ . 1990 PIS Rd. <br /> Ca"neMe CA'90040.. StDCMon CA 95215 <br /> Generators Phone: <br /> 6.Transporter 1 Company . <br /> U.S.EPA ID,Number - <br /> Haz Mat Trans Inc. r <br /> 7.Transporter 2 Company Name - ! U.S.EPA ID Number <br /> 8 Designated Facility Name and Site Addressynn U.S EPA ID Number <br /> Crosby 8�01+e3f <br /> i <br /> . nn <br /> 96M W. 17th Sheet <br /> s ENVIRONMENT HEALTH',':. <br /> i <br /> FaalPha�ieBoach CA QW13 626 482 15449 " <br /> ga• 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Ciass,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) : 13.Waste Codes <br /> ' No. Type Qua Wt.Nol. <br /> a UN1950,WASTE Am"0501S FLAMMABLE <br /> 2.1 k <br /> z 2. <br /> LU <br /> .. <br /> 'SUSS MPINT Frsm <br /> 3. lit Mi,L(F_<ED WAS <br /> r - WJL <br /> IJISi'USAL.7REA'iMENT OR MSS CItOSBl':t OVr3tTON:INC-OPQtATE5 11iL• FAC;IL!XIC SUBSTANCE coNMOL TO . <br /> t FJt-AM GRANTED t�D'i IEE-9Y 11M>4�T�CY�I ADCCORDANCE Wr171 TW PROYLS 1IS OF <br /> a'rr11 Z1EE piVptONKENTAL PRO'ECT ABLE <br /> AND 1tE[OVFAY ACT OF 1916 TOGET11M Wrim <br /> 4. OM <br /> FDERAL AND STATE PMWIA-noNS. CR <br /> TJi.�t17S TO ACCEPT <br /> THE NCM'WASTE.AND AU.TM TM WASTE HAS OWN ND1� ' - - <br /> .T[ORUryGLY- <br /> 14.Special Handling Instructions and Additional Information <br /> 9k�.1 f . aerosols .(flammable)- Profile 1' 51192 Gloves & ,Gagcjles <br /> 15. GENERATOWS10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classed,packaged,, - <br /> ' marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.if export shipment andil am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)'(d I am a targe quantity generator)or(b)('I am a small quantity generator)is true. <br /> Generalorsl0fferors PrintedlTy NaTe Signature:7 _-' Month Day Year <br /> f <br /> 16.International Shipments <br /> F- - ❑Import to U.S. -'❑Export from U.S. .- % Port of entrylexif:.' _ <br /> a Transporter signature(for exports only): Date leaving U.S.: <br /> 4 W iT Transporter Acknowledgment of Receipt of Materials <br /> Trans iter 1 Print yped Name .r Signature'-'. '. Month Day" Year <br /> ..f. <br /> aTran porter 2 PrintecirTyped Name Signa Month Day Year <br /> 18.Discrepancy - <br /> 18a.Discrepancy Indication Space ❑ Quantity <br /> ❑Type ❑Residue ❑Partial Rejection -❑Full Rejection t <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number, <br /> J <br /> LL Facility's Phone. <br /> A4 U <br /> LU 18c.Signature of Alternate Facility(or Generator) Month- Day ." Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manic except as orad in Item 8a <br /> PrintedfTyped Name afore :.Mvn1h . Day. :Year <br /> 0 <br /> 7 <br /> EPA F rm 870 22(Rev.3-05) Previous editions are obsolete. DESIG ATW FACILITY TO GENERATOR' <br />