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Please print or type.(Form desfgnedfor use on elite(12-pitchh evvriler.) „ ' ' ' • Form Approved.OMB No.2050-0039 <br /> T UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST C A R 0 C t 2 1 S 5 56 A (80G)424-989V rs ' r � . , ;l 1 C <br /> ;. ._. .Y . 0 JJK <br /> 5.Generator's Name and Mailing Address.„ Generators Site Address(I different than mailing address) <br /> Generators Phone: <br /> 6.Transpor gr'.Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Fecilq,ryry; e, epd 5 U.S.EPA ID Number <br /> 75J00 N.ALAMFOA.STR`E-T <br /> GOAIP70N CA d(a22? , ., 5 5 J <br /> Facllitys Phone: (3io;537.7:00 <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(K any)) <br /> No. Type, Quantity Wtivol. <br /> L 'fCr. x ,;,:It !,K) IU <br /> aO <br /> K <br /> Z 2. <br /> IHIS WASTE STREAM HAS BEEN QUALIFIED <br /> 3. DeMENNO/HERD00N FACILITY IN COMPTON, <br /> CALIFORNIA.THIS FACILITY HAS THE NECESSARY <br /> 4. <br /> QUALIFIED,OUR EPA NUMBER IS CAT08001aik <br /> 1.Special Handling Instructions and Additional Information - <br /> ... :. . EA7ERGEPCY C. m `OifOATREC 1,80XNAERt1 . PROFILE Or9E1:3R354 ErHYLENE :LY(GL -- <br /> - <br /> SOLUTIONSkPO,aN23.4?775 `APPROPRIATE PER30NALPROTECTIVFFQJIPM , y <br /> r,",l �' .`j f 3 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the tracer shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cerdfy that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(h)(if I am asmall quandty generator)is true. <br /> GeneratoesrORemrTntedlTyped Name - Signature-' ..-- --�/' - Month Day Year <br /> ...r 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Pon of entrylexit: <br /> -= Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TramiponerAcknowledgment of Receipt of Materials <br /> Tran rl PrintedRyped. Signature �— : .__.. _ Month Day Year <br /> a. °(F.:) yr1 �✓�,' f 'vs"//eat-- `- "cy.C�^s%'r""".�' _ - <br /> n <br /> Z Transporter 2 PnntedRyped Name "-Signature Month Day Year <br /> N <br /> 18 Discrepancy <br /> j Its.Discrepancy Indication SpaceEl ^ <br /> Quantity El ❑ <br /> Type Residue ❑Partial al Rejection Full Rejection <br /> a ds14ieren <br /> Y Number. <br /> 18b.AIIemate Facility for Genefatoi) <br /> _. <br /> U.S:EPA ID Number <br /> J <br /> IIQ Facilitys Phone: <br /> uta 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> !¢ E:MRONM£AI7AL Ftp LTH <br /> Z <br /> i Hazardous Waste Report Management Method Codes i.e.,codes far hazardous waste treatment,dis <br /> i- W g ( costa(;an systems) <br /> 20.Designated Facility Owner of Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a^ <br /> Printedrfyped Name Signature Month Day Year <br /> EPA Form 870G-22(Rev.3-0PrevictkLOitionsare obsolete. D�$IGNATED FACILITY TO GENERATOR <br />