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Please' Tint or <br /> p type.,. ,rm designed for use on elite(12-pit rewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFO'rtNi HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phar 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL0�01087i 202461-M 002034996 JJ K <br /> 5.Ger MOW Address Generators Site Address(if different than mailing address) <br /> 2788L&nAtrrle M <br /> Mw tor ,CiA I <br /> Generators Phone: M249-M <br /> 6.Tran <br /> sporter Come &L U.S.EPA ID Number <br /> CAfa0000=10 <br /> 7.Tra �ey� O U.S.EPA ID Number <br /> m MSefYlm 0 770 <br /> 8.De I%Name�d S' U.S.EPA ID Number <br /> 5181►r sR� 6CNYdfMJ��95 COfp CAM <br /> (..D8Angoliv5,CA SIM <br /> Facility's Phone: 323-277-15D <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> .HM and Packing Group(if any)) 13.Waste Codes <br /> �'jOft No. Type Quantity Wt.Nol. <br /> i <br /> Wrists,.SOS I I*cOrTf*nftd Mxie) r P 852 <br /> O <br /> W <br /> Z 2.uJ <br /> I <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information ��yy�I,, 2 <br /> S.West debris.�Sbc b1Uclab.cor tui*mked wih k* � [] ✓t/IG' —"7 ERG#171 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ale-fully and accurately described above by the proper shipping name,arca are classified,packaged, <br /> marked and labeled/placarded,and are in ail respects in proper condition for transport according to applicable internationalan national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms ofdhe attached EPA Acknowledgment of Conse . <br /> I certify that the waste mi 'mization statement identified in 40 CFR-26227(a)(if I am 8`large quantity generator)or(b)(if I a a small qua generator)is true. <br /> General rs/Olferoes Printed/Ty e e Month Day Year <br /> & <br /> —r 16.rnt4naTioiial hiipmdhis <br /> Z ❑Import to U S ❑Export from U.S. Port of enirwexit _ <br /> Transporter signature(for exports only): — ._ _ Date lea U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans ed Name Signature Month Da ti_ Year <br /> O <br /> CL <br /> co Z Tra rte,2 Pritlleped Name Signature Month Day Year <br /> Ce <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Allemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. 4 2. 3. 4, <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as need in Item 18a <br /> P nted/Typed Name /- Signature Month Day Ye <br /> -PA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILI TO ESTINATION STATE (IF REQUIRED) <br />