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. E <br /> Pleasb print or ty',,(Form designed joi use o � . Ch)typavrtker) —: "- Form Approved.OMB No.2050-0039 <br /> UI'}IFORM HAZARDWS y'Gaherotar ID - @.Pagel or 3.Emergency Response Phone 4.Manifegst Troc}kinng NN+umber y <br /> WASTE MANIFEST ,'s Fi § 0 ,,: D a :`. is 0. ! (6Qf3J gym.z7.a"'4diit"i k„`^"TT <br /> WAS JJP� <br /> S.Generators NaMatllress ITS, =rte - Generators Ste Address(ifrifarent than ma@ng address) <br /> 2'22 'a Si LAIR 90 i <br /> ,S'POCa"` ON 95215 <br /> Generators Phone: 4oa M—TIM <br /> 6.Transspportte5r�1,JC�oympyagn�y}NaTmgy�,, p�g��;1'{ry{�,,p �,e'{yq ,rv�p - U.S.EPA ID Number {, �y 'T <br /> L'.a,e'.�l'Wb z'2fL9Sr-n0[WH'SI TAA .'rM�i'MTJI'N.B C' A D 0 2.. 4 2 i f 0 3 ¢: <br /> 7.Trensporter2 IYtpany Name I U.S.EPA ID Number <br /> 8.Desingnated Facill NamsamJHios Address U.S.EPA ID Number <br /> . i3fi�'it0 f' I CII)OON . <br /> v"SYS 1q. .Ai'A A :�i'nn <br /> +'t INYO'd CA 99222 <br /> Faalht><s Phone: <br /> (310l037-7100): C e T0 #) 0Y 0 2 3 ? e <br /> ga, -eb.0S.DOT Description 0ndudtg Proper Shipping Nemo,Humid Class,ID Numb", 10.Ccnlaioers 11.Total 12.Unit <br /> and Packing Group(Rany)) No, ;Marr Quantity WINOI. 13.tussis Cerise <br /> HM <br /> p. 1"FY1R:f-.T}P➢35 Ta3TT$737L"Stt4" L3@'9''TF X.rftF3T's1 t8T'r'TTsdT SRlg' eIT 7�� <br /> CL"t4:i,`1& SCa„3?'PZL1Hd3) <br /> z 2. <br /> w <br /> 4. <br /> ( <br /> 3. <br /> I <br /> i <br /> II <br /> 14.Special Handling Instructions and Additional Information <br /> T2+€ERGEaNCY CONTALT T f:MMTWWC 1•- (?0-?)<d^.33flt4 i3A It+•;y ' rt1 i"", F' PROFILE # 93 <br /> 493641 STSCYSMWE GLYCOL SOLUTIONS PO* Ai.1.4, ' 1656 * :APS'i'l I'ERSCNAZe PROTECTIVE <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION,Fhereby declare that the contents of tins consignment are fully and accurately descibed above by the propershlPPNg name,and are desslted,packaged, _ <br /> markedand Iabeledoacarded,and are in all respects In proper condition for transport according to applicable International and national govemmentel regulations.Ill shipmentand I am the Primary <br /> Exporter.I caNfy that the contents of this conslgnment conform,to to terms of the altadred EPAAcknowtedgment of Consent. <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(If I am a Wge qumn0ly generator)ar b am a small quantity generator)is true. <br /> Garr storslOteroess <br /> . Pnnte"dlTLy,rp�er'd Name <br /> me ' S �.-.r .. i Day Year <br /> a ({7 ; ! <br /> -V <br /> 15.International Shipments S <br /> F - ❑Impodlo U.B. - ❑Exportfrom U.S: Pad will <br /> = TransportersiaNre far n <br /> g ) exports Doty): Date leaving U.S.: <br /> w 17.TmnspoiterAdmo0edgmenl of RecefptofMaterials <br /> jj Tr oMar PdntedRygad.Nam -- Signature ^" v,�. -- Month Day Year <br /> rCiZizr ^r"'G»"f <br /> transporter Pl`htedm/ped Name' hgnature -'° \ With Day Year <br /> 1 18'Dss'—pany ,,n <br /> I 18a.Discrepancy Indication Space ❑,Quaritiry Type �. LJ Residue J ❑Full ReJaction <br /> I�77 ii ❑Partial Rejection <br /> 2W Menlfeet Reference Number. <br /> 18b.Alternate Facility,la Generator) 1a U.S.EPA ID Number <br /> ENNIRF'ONVEN j AL FIF?.LTH <br /> a ;"',; ”. s EMyl�ITC;i!GFC,".':;ES <br /> tL Facility§Phone: <br /> w 18c.Signature ofAlrernate Facllity(a Generator] Mont Day 7aar <br /> Q <br /> s <br /> H18„H Mous Waste Repot Man agement Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) - <br /> O 2 ;$ 3' - 4 <br /> 20.Designated Faclity Owneror Operator.Certification ofrecdplofhmrdous materials covered by to manlfealaxcept n2t in Item l8a <br /> Pdnte ypetl Name i Signature ay <br /> } ( <br /> EPA Form 83002(Rev.3-05) Previous editions are obsolete. DESIG4AnFACIUTY TO`GENERATOR STATE (IF REOUlRED) <br />