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Please p n'lor'type.(Form designed for use on elle(12-pitch)typewriter.) ry'"�' + '��` Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator 10 Number ' 2 Pagel of 3 Emergency Response Phone 4 M N T con ugtle <br /> WASTE MANIFEST ;�.i�8 S+Sfiw7 ;t ? s_K#?i�f7_:'7 ,? jay +. j FLE <br /> S.Generators Name and Mallirg Address Generate"Sm Actress(if different then mailing address) <br /> "117 <br /> cD, Ee7c 3�?�i ?- eii{;'C,11.7Ti?`f CL.UN�L 't <br /> :NT:Gl1sr giant;-5;�a+, eg.9rit :, C:?. 2vFat"; 3430-zi?C4i: i"�3C'i:7Gtt .+, 3521Xs <br /> Generators Phone: <br /> 6 Tiansporterl Company Name U.S EPAIDNumber <br /> is t*I J'wi s?,'9 i3 <br /> 7 Transporter 2 Company Name <br /> U S.EPARNumber <br /> S.Designated Facility Name sand Site Address kj US EPA ID Number <br /> ;_)ae?--riot:Il - wr: <br /> Ii. i:•.t"� . i, 7'.n3;N3 tai. :`; Tti;1Er3it". Iry <br /> Faafitys Yham: <br /> 9a 91a 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 Gmup(If any)) No. Type Dumbly WLIVol. <br /> 1 .RrAa6fS` f'.�� <br /> C1)r a-O Ll ca �q rJ.t i 2 ' <br /> o t"�Utd. 3atC. ifi0i' dt;�. i1.3>'., e s0 r. T 1 <br /> Q ':I ,.if`1 <br /> w <br /> a 51HUM HAS BEEN <br /> 4w' FOR RECYCLING/TREAIXENTAT THE <br /> DeMFNNn/KFPPnL'N (,, ) <br /> 3 CALIFORNIA. THIS FACILITY HAS THE NECESSAR <br /> PERMITS TO RECEIVE YOUR(HASTE STREAM AS i <br /> 4 MfIta OUR EPA NUMBER is 68,11.101JUlij <br /> i <br /> 14 Special Handling Instructions and Additional Information <br /> 15 GENERATOR'SIOFFEROR'SCERTIFICATION: Ihereby declarethat the coolants of this consignment am fully and accurately descried above by the proper shipping name.and are classified,packaged <br /> marked and labsedldacarded,and are in all respects in proper condition far transport according to applicable international and national governmental regulations if export shipment and l am the Primary <br /> Expoder,I arty that the contents of this consignment conform to the terms of the attached EPA Ackrowledgment of Consent <br /> I ceri that the waste mtnimUation statement identified in 40 CFR 26217(a)(A I am a large quantity generator)or(b)(if I am a rpamty generator)is true. <br /> rteratoslOXerars PfntedfTyped Name 9na are ,/� on ay ear <br /> 1_3;ny i1+I°Js:;t't!'t..4? BWCi Oh tun=l i.�;s Gi y^ye,ft53 atCf '..*e-.-- <br /> 16 International Shipments <br /> L. ❑import to US ❑Export from US Pod ofenhylexit _ <br /> = <br /> Transporter sinature for experts cnl : Date liarting US.'. <br /> W 17.TnanspaderAck ovledgment of Rai of Materials <br /> Transporter 1 Pd dRypad Name bgraeurer Month Day Wear <br /> C Tmnsfawer.�Prfrj[Typed Name r ign re ay ea <br /> l tij <br /> 18.Discrepancy I--I <br /> 18a Discrepencylndicam,Space El Quantity ❑Type Residua ❑Partial Rejection ❑Fall Releation <br /> Manifest Reference Number, <br /> 181a Ahernate Factlitp(or Generator) ILAkk—y US EPA ID Number <br /> � 1 <br /> L1 2 <br /> LL Facili aPhone: <br /> w Ilk SignaWm ofAriemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste tfemmanl,disposal,and recycling systems) <br /> 0 1 2 3 4 <br /> I r <br /> 1 20.Dssignatue Facility Owns or Operator.Certification of receipt a ideas materials covered by the manifest except as rwled in Item 18ai <br /> ftrWyped NameIF Signature `j Monts Day <br /> year <br /> EPAForm87M22(Rev 3-05) Previous edilionsamobsolete ( I DESIGNATEDFACILIT",ToGENERATOR <br />