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Please print or type.(Form designed for use on elite(12-p@ch)typewriter. <br /> Form Approved.OMB No.2050-0039 <br /> 1 UNIFORM HAZARDOUS 1.Generator ID Number Z Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> I WASTE MANIFEST r:-r�l-'• ,,<. JJK <br /> 5.Generators Name and Mailing Address Generators Sile Address(a coherent than melding address) <br /> Generators Phone: _ <br /> 6.Transporter i Company Name r U.S.EPAID Number <br /> 7Tnser2 m�pap1je�` U.S.EPA ID Number <br /> d .r .-_ ,,-'r;.,�� rrr !�y...�/ �rg;" ra`t .� 'y1''®.sv" C,fi � �•P'y9,�,.���`� ';�✓'9`�,R'`,r'6, <br /> 8 Designated Facility Name and Site Adddss - U.S.PPAID Numbet y, <br /> uJ.i�. <br /> Ln° jE=.sa �9.Cts 8C!St3 <br /> FactiOys Phone: 137.r-44's <br /> ga, 9b.U.S.DOT Description iincludi g Proper Shipping Name,Hazard Class,ID Number, <br /> erd Packi Gou clan 70.Containers 11.701al lZ Unit <br /> HM n9 p( Y)) - No. Type Quantity vvUVci. 13.Waste Codes <br /> 1. <br /> DID 9 f:!ldTS 7Aa <br /> y� !� <br /> W2. .-r °Fy "�9`_ •-- 'J'A §A! �'r .`"- r -r -: r <br /> - <br /> ��� ,t <br /> 3. <br /> THE MaUOKM WASTE WAS 7R <br /> AND EATID <br /> STANDARD MANDA !Y <br /> 4. S.i�iSA!xxl�Db79LiCTS.WA.S1E 7REA71,IE\T t5 LE OS ANGELES'CDL NTY <br /> Gt tT,iteN. LNC, BV Tit. AR 71 <br /> OF 'rU S RSTAANCE W,PEINITS GRA'rED To OL no Er}{6p O+ Y� <br /> F.':'.�['�\ate-{#L pgp7Er-<>ON AGE\'CY LS ACCORDA\' N'rr1I TI tE OVLSIOVS A <br /> AND OF THE RES. IM <br /> �=S S�f�ATFUN NELC3VERy' OF 1976 TO WITS-1 GBLE <br /> FJ{A- AND <br /> 14.Special Handling lasWLti00e and Additional lnkflfiOT, R-.aSTE ASD ALL TF¢ N'>STE H>S aF£.' 1 .ImjZ'0 IN Al'LDRDANCE WTIN p �p <br /> _ ���r-^ROpC--"ON'6S.SUCH n1T Tim❑'FT¢I STTT i1O�..0 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this amsignmentere fully and accurately described above by the proper Shipping name,ad are classified,packaged, <br /> marked and labeled/placarded,and min all respects In proper condition for transport according to applicable Intemabonaland national govemmentel regulations,If export shipment and I am the Primary <br /> Exporter,Ice*that the contents of this consignment wdmm to the terms of the attached EPAAdmowledgment of Consent. <br /> I caddy 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 true. <br /> Genamtoesl0lfemfs Printad/Typed Name SignaWre ffWlh Day Year <br /> -71 <br /> N .yam <br /> �,`r.I-..n, j r'} §'y f° ,,,.E rm^` ...F . .•'./,f c.F� �i�? iy b, f.. <br /> ...r 16.International Shipments " <br /> z ❑Import to U.S. LJ Export Tran U5 Port of anbyO* 69 <br /> Transporter signature(for exports Doty): Date leaving U.S.: <br /> w 17.TruspoderMlmowledgment of Receipt at Materials <br /> 0 Tmnsporter 1 Pdmedr rd Name .� SignaWre s-5`+ Month Day Year <br /> aZ Transporter Pnnledrpypetl Name 1, Signature ez' Monaw_ DaY Year <br /> F '.s C n ` <br /> I s' <br /> tlle�Discrepancy Indication SpaceFu <br /> ❑ Ouanhty ❑Type ElResidue ❑Partial Refection ❑ 'fl Rejection <br /> "MenddstRefeance Number:- - -- - - -- <br /> 18b.A8emate Fadity(or Generamr) U.S.S EPA ID Number <br /> J <br /> LL Facility's Phone: <br /> w 1&.Signature OIAltemete Fadity(a C>°rleretor) <br /> I Month <br /> Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> 20.Designated Fatty Owner or Operator.Certification of mosiptof hazardous materials covered by the manifestexcept as noted In Item 18a . _ - <br /> PamedllypedName signature m - Month Day Year <br /> EPA.JEqrm$700-22(Rev.3-05) Previous editions are obsolete. EIY IIFF"A <br /> �%ESPGhdAi'ED CILITIT TO CaEfJER.G"€OR <br />