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10 <br />Pease print or tune. (Form lesioned for usa an Pliba, M-nkhl hmpwdtpr I 17nm, Ard—%-4 rUR <br />l:VA Form d[UU-ZZ (Kev. 3.Ub) vrevious eartlans are Obsolete. DESIGNATED FACILITY TO GENERATOR <br />f7,64 t't <br />UNIFORM HAZARDOUS <br />ID Number <br />Z Page I of <br />3. Emergency Response Phone <br />t V4&d <br />WASYE11111"ffsT <br />rat i -'-Om <br />1940 <br />4VA <br />016 3 17 J'A <br />5. Gage &x%NamexWMaftAftesi (EdAfereM Oren nreZrhg address) <br />P, 0 M?2 <br />We. CA 91 XW IUD N. fta0w *M <br />SWoWn, CA WPM <br />U.S.EPA IDNumber <br />7.Transporter2 Company Name U.S. EPA H) Number <br />U.S. EPA ID Number <br />F.cWs Phone. <br />ga <br />9b. U.S. DOT Desuipfion (xrdudk)g Sho*g Name, Hazard Class, ID Number, <br />10. Containers <br />11, Total <br />12- Unit <br />11 waste codes <br />No. <br />Type <br />HM <br />and PaciftGroupffany)) <br />Quantity <br />WLAfol. <br />W-4PPA i4werda71. C'vM*---'ffW Dems <br />W <br />.3i.i-2 <br />Z <br />LU <br />2 <br />3. <br />14. Special Handling Instructions and Additional I ormation <br />ftvPMwF1,Pk <br />15. GENERATORIKWTEROWS CERWFA <br />: I hereby declare that the carters of this co;p9unerst are h* and accurately described above by the Koper stopping name, and are classified, packaged. <br />marked and labelediplacarded. and are inal <br />. he� m pmw conclitim for transport accoafhaipapplicable international and naWW vmrn mental regAafiors. If wport shp—t and I am the Primary <br />ExporW I m * thal the conterds of Ints cor� <br />milarm to the terms of the altachad EPAAdwwledgment of CVWlt <br />I off* M the waste mmmzation statemen <br />identified in 40 CFR 26W(a) (d I am a bW gjan* generator) or (b) (d I am a .quantity wnwaW is true <br />GeneratolslOsarors Fy,el Name Signature Month Day Year <br />til <br />4 <br />� <br />-j <br />r-- <br />16. Interne tional Shipments <br />0 import to U.S. ETEIPd from U.S. Port of <br />Transporter signature (for exports only); Date laaving U.S.: <br />E2 <br />Uj <br />17. TransporterkViawiledpent of Receipt of Mateliats <br />Transporter I Prirdedlfyped Name Sgnature Month. QW <br />Lyet <br />'7-06g' <br />0 <br />0. <br />Z <br />Trarkspader 2 Printadffyped Nam Month Day Year <br />............ <br />18.Dwepancy <br />laa. Discrepancy Irdcadon Space ElouNoty F1 Type Residue Partial Rwcdon ❑ Full R*,ction <br />Manifest Reference Number. <br />r-: <br />18b. Alternate Facility (or Generator) -U.S. EPA 10 Number <br />-j <br />U <br />IL <br />FacMVs Phone: <br />Uj <br />18c. Signature ol[Abwnate Facifity (or GeneraW <br />Moft Day Year <br />19. Hazardous Waste Report Managemvrl Method Codes (Le., codes for hazardous waste treatment, disposal, and reqdiV WSWM) <br />01. <br />12- <br />r <br />4. <br />20. Designated FacuNty Owner or Operalor CeMof receipt of hazardous materials cumed by the manifest except as noted m Item I Be <br />PrinfedlTyptd Name 5Nrlature Month Day y <br />l:VA Form d[UU-ZZ (Kev. 3.Ub) vrevious eartlans are Obsolete. DESIGNATED FACILITY TO GENERATOR <br />f7,64 t't <br />