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,'Please print or to.{Form designed for use an elite(12 rtch ,ypewn#er) Farm Approved,OMB No.2050-0439 <br /> UkFOR WHAZARDOUS 1 Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number ' <br /> 9. <br /> WASTE M T 000 _JJK <br /> { 5 Ge ors tJame and Marling Address = Generator's Site Address(if different than mailing address) <br /> t <br /> "w.P C�Iffferrtj*;5.2Q0'ShBils Street ' 1990 PltxdRd..: <br /> �erce CA 90D0 S"lodeton CA 95215; <br /> Genereto Won. <br /> S.Transporter 1 Compan e . `U.S.EPA ID Number' ; <br /> HaZ Mat d. <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 /> ro-S 1N&1 `th <br /> ypr 888Crt CA 90$13 <br /> Feu 1 s one: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,N?Number, '10.Containers 11`.Tota], 12 Unit 13:1Nasta Codes <br /> HM and Packing Group('dany))° No.- Type Quantity Wt.Nal! <br /> 1.WASTE A 5' r343 <br /> X :2.1.UN 1960 <br /> a 2. - <br /> LW9 <br /> ' <br /> 3- <br /> , <br /> 4 .. - _ .. <br /> 14.Special Handling Instructions and Addit"tonal Information <br /> 9b 1) aerosols Profile #51192 + Gloves & Goggles <br /> J. <br /> •p� .:_[-a.ry ," -f F ,<„ _ t- w..x,.; w�l«,�✓:-,.,ti r i �le,, r-+., r ....q„r <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION I hereby declue that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged;. <br /> marked and Iabeledlplacarded,and are in all respects in proper canditlon for Vansport axardtng to applicable international and national governmental regu#ations.If export shipment and Ifaim the Primary n <br /> Exporter,I certify that the'oontents of this consignment conform to the terms of the attached EPAAcknvwledgment of Consent <br /> I caftify that the waste minimization statement identified in 40 CFR 2617{a){-d I em`a large gnanUty generator)or(b)(I I am a small quantity generator)!s hue <br /> Generator Ofteror's PrintedrTyped Name.- Signatures ;Month Day Year <br /> IrA <br /> 16 Intematianal Shipiments <br /> ❑tmRart to U S r w ❑Export ftom U S Part of enhylexit. <br /> TransportensEgnalure;(torexcaorts only} f "'Dataleaving EJ S.r _ _r <br /> :.. <br /> 17:TraneporlerAcknowladgrnent of;Receipt of Materials <br /> Transpo i. rint . yped Name'; 5igneture > Month <br /> i•PDay: Year <br /> try <br /> Z poder Pdntedfryped Name- igna n ,Day . Year 3 <br /> a - <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication 5paoe ue, <br /> © Quantity Type .' ❑Resid : ! ❑Full Re <br /> Partial Re ec r jecbon <br /> Y +� _l��� <br /> !�-. 1.f E0-wAS7 WAS RFIA <br /> ECEIVI . NDLFA ANO Sit]MrP1.FOR:S[1BSEl}1 r1t a <br /> VlSAOSAI:TIt ��'AENT.OR RF�ISE CROSS t. V 14N,iNC.OPERANT> E OAC4n70GE <br /> 18b.Alternate Facility(or Generator) !'EW[I <br /> J <br /> WTSIl TIIE Qdir3RONri£YTAL PROTECTION-ACES!ICY.W ACCOItDAN41E WTIb, <br /> CS CONSERVATION ND.RECOVERY ACT OF,.1976.FOGEf?� TW.NE fESS <br /> Q FFAFiIAL' 11ND 3TA1E,'REGUU►71UAr5:.47t051 Y R.,OV-AU T NAS.`ALL_ <br /> Fadlit�sPhone ) N�WAS Att>3 ALL TIS WA Fi3 ))F17Si'_KANDL$D, t <br /> T�5 <br /> WU 18t.Signature ofAltemate Facility,(or Generator) ACp1tDIFIGLY ; ' Month, ':`Day Year. <br /> Z <br /> 19.Hazardous Waste Report Managemerii Method Codes(i.e.,'oodes for hazardous po g ys <br /> Waste treabnent,dis sal,and .` m - <br /> O 1 <br /> 20.Designated Facility Owner or Operator.Certification of re hazaniaus materials covered by the exeept n Item 18a`.: , <br /> PnntedrTyped Name Signature Month Day, Year <br /> EPA Form 8700 22(Rev 3-45) Previous eddions areobsole DESIGNATED FACILITY RAT r reed5 <br />