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Form Approved.OMB No.2050-0039 <br /> (12-pitch)ty ewriter. 4.Manffest Tracking Number <br /> Please pont: r�+pe•(Form designed for use on elitetypewriter.) 2•Page 1 of 3.Eme{gency Response Phone 003568186 JJ K <br /> 1.Generator,ID Number d402 2pQ-2d9-3500 <br /> UN FORM HAZARDOUS �v.-�►�►�+'� <br /> WASTE MANIFEST Generator s Site Address('rf d fierent than mailing address) <br /> 5.Gert g Address <br /> 276 Bt#bon Avenue <br /> Meme,CA M36 <br /> 209-249-3500 U.S.EPA ID Number <br /> Generator's Phone: CAR000WN10 <br /> 6.Trarispo r 1 m n ame 6 Litho <br /> l O U.S.EPA ID Number <br /> CAD028277038 <br /> 7.Tran er 2 pany Name <br /> ddddrree U.S.EPAC Number <br /> 703M <br /> B.Des� �Oly <br /> tsosSsCA 90056 <br /> Facility's Phone: <br /> 323.277'1 SM 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No. Type Quantity Wt Nol. <br /> HM and Packing Group('rf any)) 4 <br /> 11 IV <br /> 1. O of U <br /> cy-o <br /> O <br /> Z 2. <br /> W <br /> O <br /> 3. <br /> 4. <br /> - <br /> 14.Special Handling Instructions and Additional Information EF�t3#171 <br /> >a�l� ink #W305-03 C <br /> 1rJ.WeBb115.�� <br /> y y y proper snipping name,and are classified,packaged, <br /> re that th for transport according to applicable international <br /> marked <br /> national governmental regulations.if export shipment and I.am the Primary <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION-.tes respects-inproper declare that the-contents of this consignment are full and accurate) described above b the p Pe PP 9 <br /> condit <br /> t. <br /> marked and labeledlplacacont and are R - a all quantity generator)is We. Month Days Year <br /> Exporter,I certify that the cenzation stale mot identfednsignment cefnn40 CFR 262.2 (if I am a.large quantity generator)or(b)Ci O 5VC <br /> I certify that the waste minim Signature ` <br /> Generator's/Offerors Printed/Typed Name <br /> 17 - d <br /> --�Export from U.S. -Port of entrylexit: <br /> 16.Intemational Shipments ❑Import to U.S. Date leaving U.S.: <br /> F <br /> � Transporter signature(for exports only): Month Day r <br /> W17.Transporter Acknowledgment of Receipt of Materials Signature / O ` US <br /> � Trans' el Name �•W" Month Day Year <br /> O Signature J3 l a <br /> a <br /> Z Transporter 2 Printed/Typed Name <br /> Q ` <br /> � Full Rejection <br /> Partial Rejection <br /> 18.Discrepancy ❑Residue ❑ <br /> 18a.Discrepancy Indlration Space El Quantity <br /> Type <br /> Manifest Reference Number: U.S.EPA ID Number <br /> 18b.Altemale Facility(or Generator) <br /> Month Day Year <br /> U <br /> tai Facility's Phone: or Generator) <br /> W 18c.Signature of Aitemate Facility <br /> Q <br /> Z i e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> (? 19.Hazardou Wast Report Management Method Codes(i. 3 <br /> us 2. <br /> 1. <br /> 20.Designated Facility Owner or Opera or.Cert fication of receipt of hazardous materials covered by the manifest except as noted in it 18a <br /> 11 Month Day Year <br /> lIM Printedffyped Name REQUIRED <br /> �n <br /> `1' __ nhcnlPtP DESIGNATED FACILITY TO DESTINATION STATE (IF <br />