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.ease print or type. (Form designed for use on elite H2-nnrhlT„e,,..e„n <br />• <br />.I <br />_ —`""`•""""r - <br />UNIFORM HAZARDOUS 1. Generator IDN'umher 2. Page 101 3. Emergency Response Phone <br />WASTE MANIFEST C1�2 p'q�j 21G <br />Form Approved. OMB No. 2050-003f <br />4. Manifest Tracking Number <br />f yU�—xg —yO 009479250 JJK <br />5. Generators Name Mailing <br />and Address (3enerators -le Address is different than mailing address) <br />ZZ Z Z S S/�1/CGA ( /P A tJG <br />Generators Phone: arZ V -7-2V CA <br />6. Transporter 1 Company Name <br />U.S. EPA ID Numher <br />CA= <br />7. Transporter 2 Company Name <br />U.S. EPAID Number <br />B. Designated Facility Name and Site Address CG67++Ax �FArtQo�S� 10 --LG <br />U.S.EPAIDNumber <br />iyy--a��Gn.rz.ye:�s.� eel, <br />Facility's Phone: ,dA( A+! XV CA J�S-131,7 <br />go. <br />HM <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />10. Containers <br />11. Total <br />12. Unit <br />No. <br />Type <br />Quantity <br />Wt./Vol. <br />Q. Waste Codes <br />t/A 30 9 �d tlyY7rLi >ASr� <br />W <br />r81 <br />slJLIT) ti1.D.S•4,l -VAA0-1S)1 f, Py/J) <br />1 <br />k4 <br />4. <br />14. Special Handling illtmIlions and Additionalo <br />InfrmationE-6�1 <br />(� <br />Peo <br />4U14 <br />ENVIRONMENTAL HEALTH <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: (hereby are that the contents of this consignment are fully and accurately describedabove by the propershipping naF-P PF <br />me, sifted, packaged, <br />marked and labeledlplacarded, and are in all respects In proper condition for transport according to applicable International <br />and national governmental <br />I cedify, flat the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />regulations. If export s <br />shipment and am the PrimaryExporter, <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) Is We. <br />GeneraloeslOfferoes Pf tedTryped Name Signature <br />/I LAioi <br />&tenth Day Year <br />—r <br />z <br />.A <br />16. Inlerna6onal Sents <br />hipm <br />Import to U.S. <br />❑ ❑Expel from U.S <br />J 12- ?-1 LZ <br />Podof enirylexii: <br />Transporter signature (for exports only): <br />w <br />Dale leaving U.S.: <br />17.TransporterAcknowledgmenlof Receiptof Materials <br />OTransporter <br />l Printed/Typed Name Signature <br />g <br />n. <br />l <br />Month Year <br />_ure <br />�Day <br />nat <br />Month Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑Type ❑Residue <br />❑ Partial Rejection EJ <br />Rejection <br />18b. Alternate Faciliry(or Generator) Manifest Reference Number. <br />� <br />U.S. EPA ID Number <br />U <br />< <br />Faciliys Phone: <br />W <br />Ise. Signature of Alternate Facility(or GeneraloQ <br />ZMonth <br />Day Year <br />TA 19. <br />F1. <br />Hazardous Waste Repel Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. 3. <br />4. <br />20. <br />PrinledRyped <br />Designated Facility Owner or Operator. Certification al receiptaf hazardous materials covered bye manifest except as need in Item l8a <br />the <br />Name <br />Signature <br />Month Day Year <br />EPA Form 870022 (Rev.3-OS) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />