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I <br /> rl. r LO w1t � Form Approved.OMB No.2050-0039 <br /> tI9 i Response Phone Track Number <br /> Number�WW194837 e 1 of 3.Emerge � <br /> 3 If # C ` 45N13009430654 <br /> r . <br /> JJK <br /> .1 VD � -FS., EA W3 <br /> � ' Generator's Site Address(If different than mailing address) <br /> 7 <br /> . kf t'CT ti. W)TCE Df,7r'. / r/r� U.S.EPA ID Number <br /> r�-_tr')rA BCit3 '1(5k,iS,di1»"k.)4'��tii <br /> M (^)Gfr <br /> 446 N Aurora a StL� U.S.EPA ID Number <br /> 44 {JC52"0L' DafI or Kelly <br /> U.S.EPA ID Number <br /> BODY SHDP N0. DEUVERY CYCLE f C To SI ru; <br /> / r/ 10.Containers <br /> '144 <br /> l:= ; 11.Total 12.Unit <br /> RCcaUN m NAME, No. Type Quantity Wt.Nol. 13.Waste Codes <br /> _ t ,_. <br /> AUTOMATICALLY <br /> t it , <br /> :'- �{� TO INSURE YOU <br /> «, <br /> PRINTED .e= OF ACCURACY L---- - -- <br /> RODU4TN0. iJ <br /> DESCRIPTION fU8 4 <br /> i <br /> � ,3E--B Waste Only 30g drum <br /> tti•IF2if)F..RE,; s'ft':'t' CE)P1IACT r k ?#tiC i,1F,k (?Oki <br /> .�{ a nment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> IMENTS to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> i q P Acknowledgment of Consent. <br /> tity generator)or(b)(if I am a small quantity generator)is true. <br /> 'f� Y-F.tIsrdwg 2 ' '��l '� �"f",:'.' s, „J nature MQntt+` pay Year <br /> f,'ryyy ),;;�}j T F. (`y jC,(�' RF`L. 'CCD T�i�il', .M 3s — !rt from U.S. Port of entry/exit: <br /> !1. R� (DWI) 21 / ��� Date leaving U.S.: <br /> 3EiS WASTE-I zD-41#11 P$t <br /> Signature Month, Dgy Y/ear <br /> F I f <br /> WEIGHMASTER CERTIFICATE I I I 1 <br /> IS TO CERTIFY that the following describ commodity was weighed.measured,or counted by a weighmaster,whose Signature Month Day Year <br /> 3ture is on this certificate,who is a ogni: authority of accuracy.prescribed by Chapter 7(commencing with Section <br /> bl of Division 5 of the Califomi�9usiness a Professions Cod ad r�iinisterod by the Division of asurement Standards of ' <br /> :alifomia Department of Foodmid Agricu <br /> Ml- <br /> WEIGHMASTER;BYi JC <br /> DEPUTY i <br /> __LL i ❑Residue ❑Partial Rejection ❑Full Rejection <br /> INSERT,0�6i DOWN THIS END FIRST <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) _T <br /> onth Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br />