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Form Approved.OMS No.205.0-0039 <br /> Please print or type.(Form designed for use on elite(12-pitch 1 pewriter. 2•Pae 1 of 3:Emei�gggg��ygyy Vg Aa�- Qhqqg 4.ManifestTracking <br /> 'Number �^y'`� �� <br /> UNIFORM HAZARD0U3 1:Genorelor lD Numblf�At'E60023162; (CtA14 9h,500 0Q,6 ! 6', 1 <br /> WASTE MANIFEST Gerremtots 3iaAddrese(il tllgerenl Nan malting address) <br /> 5.Generators Name and Mali gAddress <br /> Viti€;dt t"1 PiY)ljkK4l,)I t$9 No CHA Attr1; Dor0k E 1'drntarl t:hicy, A Wi Hnnven�taa <br /> Kgff,t o 1(tnrrtu C)t►vq,I,utA5ru5poUs,iW 4@J7N <br /> '➢Mcy,CA 25.3'77 <br /> Generators Phona: f31(" �"� ►r - ' U.S.EPAID Number <br /> 6.Transporterl Company Nana CAROM 141133t'. <br /> AInottAii 111te(pleai t-etvF en,Fntt.' U.S.EPAID Nnmhar <br /> 7.Transporter Company Names' <br /> U.S.EPA ID Number <br /> e.Designated FacllllyNeme sod SgeAddress <br /> marl HIThoff)ArevDitw r,{LG wRrlftC mmi552W <br /> 11GtK1 Nnrth At1io��Dy1rt,(irzr)saNifl,ll1"ltg1p3311t+A <br /> Facllilyrs Phone: xla�,r9-ttl'�1�Q <br /> 10.Containers 11.Tool 12.Until 0.waste Codes <br /> 9a Sir.U.S.DOT Descrptionfnduding Proper Shipping Nems,Hazard Class,ID Number; No. Type quantity WWoI. <br /> HM and Packing Group ff arty)) 11+1 )t IVIft <br /> 1.I10,)Jt`Y8176,WA51111 s(M.1AS COMM - E-4.AM#111I'.•4FT [l� � <br /> �.. <br /> o �.a.s.,tA�:stns"►�n•ecrHTAtMwc'�r�trraa►,ratn�Prt�ulc;rr>. ;,;,,•:;• .I'ry .�.�� <br /> a 4A,PO 11 PIT lnajjaGt<iC;1'33 <br /> LU <br /> z 7.. <br /> W , <br /> (D <br /> 3. -- <br /> i <br /> 4. <br /> 14.Spedat Handling ins i andAddlli not Info alio ,/' <br /> VYrrarA e>w,l�u�PIA" �.la�ilkdhnrtrltlrlU. V1iri111rlr,or i'+n; rr. .: 7.1G2�iE*8 C';ttly1061)2t.3 4 <br /> vnhoneef; appltwlmato. 24 hulrf0ffwI fe1%.y ntrnlhr a (LVF11) I Ftit'ka;,: GH318 t0SOMtJ i2AH t��d �, ! <br /> 4244R)O 0kenitt;a0,Adi>fflbtIds f)OIltdNhlUibd Wtih tattoo 1ddi CH i78a34S S(7tr <br /> 15.. marked ab led paRrarded end aleinallr spectsreby declare that the contunts.1 INs consignment are fully aIn proper condition for transport eaordlog to applicable Internationalaccurandnalohal governmental gula8ons,D by the proper ldpexport shipment and lesm the Primaryd� <br /> Exporter,I early,that Ne contents of this consignment conform to The arms of the attached EPAAcknowledgmenlof Consent. <br /> I ceNty that he waste minlmfzalan statement Id in 4o CFR 262vo)(if l ams large quanllly generator)or(b)(1U am a small quantity generator)Is true. <br /> Man Day Year <br /> bignalum. .1 la <br /> Generaloesl0fremes Pdnledlryped Name - <br /> AGr an UPONIf Of OPUS-J Sherman <br /> —f 16.International Shipments ❑Import to U.S. ❑Export from U.S. Podofentryleu4t <br /> F <br /> z Transporter signature(for exports Only): Dale leaVing U.S.: <br /> CZ 17.TransporterAcknavledgmenl of Receipt Of Materials Mone , ay Year <br /> 3igealure <br /> F-' Transporter l Pdnledrryped Name, <br /> O !x •pr(,'" x�itl 14. t ,s �!(c.. �./°.,�i.'l`°'1+11'w{"o Day Year <br /> o- Signature <br /> z Transporter 2 Pdnredrryped Name <br /> 10.Discrepancy <br /> 18a.Discrepancy Indication Space �Quantity �ryPe <br /> LJ Residue <br /> ❑Partial Re)eclln Full Rejection <br /> Montreal Reference Number. <br /> U.S.EPAID Number <br /> 18b.Allemale Fadlity(or Generator) <br /> I Faclllys Phona: - Month Day Year <br /> 0 10c.Slgnatuie of Allemale Facility(Of Generator) <br /> 19.HazerdousWasle Report Management Mothod Cadea(I.e.,wdas(orhomrdouswasle Imalmenl,dleposel,sndrecydingsyslems) 4, <br /> G 1. 2. <br /> as tided In Item l8a <br /> 20Aesignated FacNlyomerer Operator.CeNgcalonofmceiptafherardousmaledel'covered by the mSnloalureeapl Month Day Year <br /> PdnledRyped Name _ <br /> GENERATOR'S INITIAL COPY <br /> EPAForm 5700-22(Rev.3.05) Previous editions are obsolete. <br />