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Pleasa print or type.(Form doslgnad for use on elite(12•pden)typownlac) Form Apprmed.ON%No.24500039 <br /> UNIFORM HAZARDOUS I.Ganorator ID Number 2.Page 1 of 3.Ernergoucy Response Phone 4,M(a�niffo9sl Tracking Numboorr <br /> WASTE MANIFEST CALDW.79M Qt6 371�7d7 014 ( L 3775_ J J K <br /> 5,Ganeralols Nnmo and fAaging Address Gewatnts SifeAddro,(if d11•.rant rnan mailing address) <br /> VANOERLANS AND SONS INC. <br /> 1320 S SACRAMENTO ST <br /> L001,CA 90240 <br /> Generator's Phona: �r <br /> 6.Transputer t Company Name — U.S.EPA ID Numbar <br /> MOS ENVIRONMENTAL SERVICES INC. CAD044OD35W <br /> 'ZTr ns <br /> port 2 Compan Hama RAU.S.EPA ID Numbar <br /> 8.0oslnnaledFacillyRaw and Si!eAddress TV U.S.EPA ID Number <br /> lEOU . . <br /> A�s TECHNICAL�nLLm�Ns CATI)8�1i4n79 <br /> i i2 HENSLEY STREET <br /> RICHMOND,CA MI <br /> FDililys Phone: 8'243.2382 <br /> Oa 8b.U,S.D07 Descriplion(induoing properSlilpping Name,Hazard Class,ib Number. 10.Conlae4rs 11TOW 12.Unit <br /> Hit and PackingGroup(ifonA) d3.Was!oCodus <br /> f;p. Fypa Quan!i!f 'r'J1rVcl. <br /> t UW077, WASTE ENVIRONMENTALLY HAMDOUS SUOGTANCES 00i Dm P 181 DW7 <br /> o SOLID,NOS,S, PGIII(CADMIUM,CHROMIUM)LU <br /> 3. <br /> DEC 2 2 2611 <br /> f FAITH nI:PARTMFNl f <br /> 1�1.Spatial Handling InsWcpcns andAddL'onal Infomzlioa p' <br /> 913.1)PROFILE#Jv53a+ ERt##171 j <br /> E.R. TOR' RMOS ENVIORONMENrAL <br /> HANDLERS SHOULD 6E TRAINED AND USE AP <br /> PRt�IED PPE <br /> 15. GENERATOR'$IOFFEROR'S CERTIFICATIOYi: Ther by dadan that the contents of leis censl9nmentara(;iy and aca,mtely doscrbed abore by Iho D aper sh pp'u g name,a d are cos +ad.pac aged. <br /> maland and Iabo'edVacardod,and are un at!respac's In prormrcond:tian for transport accodng to appl,'able inter"Nionaland natomdl governmrmial regu!ativns.it extwrt chipmcat and I am tiro Primary <br /> Exporter.I eertly that the conbmts of this cAnslgnment conform to"lerms of Ilse atlachod EPA Acbc Modgmenl of Consent. <br /> !coriity put Ii,e vrosla minhnizsGon statement fdenL`fied in d0 OFR 2F2.21(a)(i`I am a tame cuanUiy generator)nr(b){idI am a small guar+lily genoralar)Is tmo. <br /> Gegorator'dOftoror's PrintedfryT�ed Name S g atur tlonN Day year <br /> Y i 7 (S <br /> —j 1&.Interna hpmenis �—} <br /> Import to U.S. LJExpmlft.U.S, Port ofentrylexi(: ..- <br /> 12nspartor Signature(lar oxpods only); We lealrnri <br /> ti.Tanslx,a ArknowladgmentofReco'ptofhdatorials <br /> Traosportnr t Printodfiyped Name 5 ature <br /> htonlh Day Year <br /> to - _ <br /> Tigns o+tot�yped Namo u pn ra 1AMil Day Year <br /> 18.Discrepancy <br /> tee.Disaopancy dttdical;n Spa <br /> ra �° , Quantity �1 Type ❑Rosidue LJPa;GatRejaelMn ❑FuilRejeclian <br /> Ge <br /> y�netao Madfest Reference Numt"r: <br /> t06.AliemateFaciGty{wtar) IJ.S.EPA(OPlumber <br /> tti. Facility's Phone: <br /> t8c.Sir nalure ofAltemMe Fetility(or Generator) hinnU, Day Yanr <br /> d <br /> z <br /> 19.Hazardous Waste Report hfanagamont Method Codes(i.e..codas tcv hazardous waste IrnaEnlenl,risposad,and reryckn9 s,'stoms) <br /> LLJ p 1 1 t f�/ 2 3 d <br /> 20.Designated Facility Owner or Operator.Certification of revipi of hazardous materials covered by the rtranitostexcept as ndcd in Item 18n <br /> Prime'` ed Namo re hgt? k <br /> Year <br /> EPA Fom 0700.22(R <br /> ev.3•05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUITED) <br />