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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) &J17848V)-= FIPW Lt•1:l-11000A Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.eer�tor,lp Nin 1 d 5 8 4 7 4 2.Page 1 of 3.E�eiNA?cY Region?1�hone 14.Manifest Tracking Number WASTE MANIFEST AA D D a tf 1 fJt7�1 4if.S-:i 001834445 FLE 5.Generator's Name and MailinAddress Generator's Site Address(if different than mailing address) Cal Trans 7ildrld 16 16:14 G*UM 6 Street Swcmn,CA W, 6 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number glean Harbor pnvironmenta:Se±vi aL fn- M9 A D 0 3 9 3 2 2 2 6 7.Transporter 2 Company Name U.S.EPA ID Number 8� t�t tOt1 � C U.S.EPA ID Number 11 GM Nom App Rudd U T D 9 6 1 6 6 2 1 7 7 o►ninitw0le, err,ewe Facility's Phone: i ±k 1 ab ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number 10 Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(H any)) Na Tvoe Quantity WLNoI. 1 f E,NON 1kn 1A,tiAA�+tt�lMt WAM:�tULM.(OIL, 3€� 0 001 biq ot13°o LU _NZ11NE,NON Rr—W.HAZARDOUS WASTE UOLADS,(LATEX uJ PAINT.WATER) o0l IYV _._...__ NJINL, _W%�ftk;- llk�T ..IDL.JHY1)FAJ --- OIL.ABsORsEN (�r� ! p 00260 - - N > -K�h RaZ3 L-WASE, SO-M,NZ)N 352 ,AS -,,RUBBER) 00/ D M 0 14 Special Handling Instructions and Additional Information :� 70 j23341 ri2��4'J I �/�/y� 4 CH2341% % Ay) 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged. marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify 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. Generator's/Offerors PrintedlTyped Name tgna ureon ay Year STer J6 oLAG r+e, J 16.International Shipments i— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature for exports only): Date leaving U.S.: UW 17.Transporter Acknowledgment of Receipt of Materials U Tra orter 1 Printed/Typed Namel bignaye Month Day Year d QTransporter Printed/Typed Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q ZE Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI C 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be Printed/Typed Name Signature Montn Day Year EPA For 70 -22 Rev.3- 5) Previous editions are obsolete. DES1 "TED TO DESTINATION STATE(IF REQUIRED) cilloani IM-L) pam�fm and wfl accep'tine waste� gene-ato-is s0 pmg.