Laserfiche WebLink
Please print or .(For%designed for use on elite(12-pt!Woter.) Form Approved.OMS Na 2050039 <br /> ORM �J 1.Genemlor ID Number Z.Pageld 3.Emergenry.Response Phone lMantestTmcking Number <br /> -r w <br /> WASTE MANIFEST - _Cyr ;�-,f,;;h ,r<I r) _ ..„ n4, - , FLE <br /> 5.Generators Name and Malfirg Address .,,G'. lots Ste Address(ddInerant Man maieg address) - <br /> Twner F-rterg3'raryj; Tower M lui t 4 8,36 <br /> 24 13c1-enland int. t414 W. Yemqemitr Avfi . <br /> .r tn• CA 2 r3 i i39D' s38 Ecru Y taFlfBc e; i,! 95x32 1 <br /> .Transporter I Company Nam - - U.S.EPA ID Number <br /> E.'i'ELSHIRE i.�vJUO';83f13 <br /> T.Transporter 2 Company Name U.S.EPAW Number - <br /> IL_Designated Fadifity Nam and Site - U.S.EPA ID Number <br /> 20^eO N. .Alarnita St. f f:P 7813?;1 352 <br /> Fa�tllrdkW, CA 60222 r d nZ7 tr <br /> 9a. 9b:U.S.DOTOesciptlun(incluclintIProper SNppi g Name.Hand Class,10 Nurser, 10.Containers 11.Taml 12.Unit 13.Waste Cade- <br /> HM and Packing G-p(ifany)) - No - Type - Oumay 'WLW - <br /> UN 20'x, Ga irle Mixture, 3. PG 1! <br /> x <br /> 2. THIS WASTE STREAM HAS BEEN QUALIFIED <br /> FOR RECYCLINGgREATMENTS AT THE <br /> 3. DeMEETTKER <br /> CALIFORNIA.THIS FACILITY HAS THE NECESSARY © 17 <br /> v-voi ig wASTE STREAM AS <br /> 4 QUALIFIED,OUR EPA NUMBER is CAT080013352 <br /> �`" ON EN <br /> FJ,L REP <br /> 14.Special HaM6g Mbuctlon9 and AMD"ldomnabdt - <br /> c Tze WEAR fAL L APPROPR)ATE BE SI:211787 <br /> ER <br /> (W*. <br /> a&1Vatnr PERSONAL PROTECTIVE TO'ASR CCN; C5C123C <br /> MPTHING <br /> 16. GENERATOR'SIDFFEROR'S CERTIFICATION: I busby dedam that the conlenIs of the donsgrment are hsy and acarremtydesaibed above by tle proper s4ping name,and ane dsssaled.packaged, <br /> marked and IabeledVecarded,ars are In al respects F proper condition far banspod aaord+q to solvable Ntemabonal and national govemmenlal mgdalkns.If export shipment and I am the Proxy <br /> Exporter.I am*that the contents of he,cdnsignmenl conform to the terms of Ne Mooed EPAAdmoMedgment of Loosen <br /> I cer*that the waste rtvaniuton statament Identified In 40 CFR 262.27(x)(dl am a large quantity generator)or(b)(d l am a eneralor)Is true. <br /> yP� oma - ge ar <br /> -+ <br /> 16.International Shlpmuis ❑W-1pa to 11.5. ❑ExpM ten U.s. Pad dente <br /> TrarNsorler sionaama fa exports on : Date LLS.: , <br /> 17.Tnmpaler AdToMer grad of Receipt of Materials .. <br /> . Transpeta 1 Pehted Types Name s 1 - _ °ar <br /> Transppier2 yped Name. - Solabn _ <br /> 18.Dlaaepanry - - <br /> 189.Discrepancy Indication Space ❑ "rely ❑Type ❑ReskWe ❑PerM, Refection - ❑FW Rejection <br /> pit Rehrarca Numher.' <br /> 18b Alternate,Facility for Geodesist) - .. U.S,EPAID Nu nber - + <br /> U <br /> If Facility's Pliom . <br /> W.. 18a Signature ofAnemete Facility(or Generator) - - Monts_ Day Veer <br /> N19.Haudrdous Waste Report Management Meted Codes Ph.,dodos lot henrdouswaste t ratrent disposal,and recycling systems) - <br /> 21 Delgiaed FacAy OMer of Operator Certification of receipt of hemNcs materials covered by the manifest excokifto inNam 18a .. <br /> 11 Pert typed ma 1 "! Signamm :•:I. ..� Month Das' Yaar <br /> EPAForm 8700.22(Rev.3:05) Previous editions are obsolete.` t,t DESIGNATED FACILITY TO GENERATOR <br />