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Please orint or tvoe_ !Form riPcirurarf frw i rca nn Phtal112-nitrhl tvrwwritar 1 <br />cra runt orvu-44 tnev. wo) rrevrous eumom are olmtete. <br />y I <br />DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />f. Generator 1D N r <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Maiffnt Ira <br />6 M317 <br />WASTE MANIFEST <br />16 JJ K <br />f. t <br />Y • 7 ' Y <br />!a,Generatofs Nameand Maileg Address _ Caniiia (d different than m@W@ address) <br />P.0 aox.33172 1841) N- StB <br />LW-, CA flied <br />i�erceraibtsPitonegg ext CA 8�320l5 <br />g Transporlor i Cw"W Nme U.S. EPA ID Number <br />Yitksz* D 'f AoR "` C1k1)in4 t8f. 6 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />& Designated Facdiy Name and Site Address -- U.S. EPA ID Number <br />iA►B5x is**m Rr! <br />CA 9320A <br />7 1512 AM <br />ga <br />9b. U.S. DOT Description (including Proper Shjppirg Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No- <br />Type <br />HM <br />atd Group (d -Y)) <br />Quantity <br />Wt.Nol. <br />1. u <br />LU2 <br />UJI <br />3. <br />, <br />I <br />}"_ <br />4. <br />j <br />14. Special Handling Instructions and Additional Infartn tion <br />ERG 1 T1; Prf� INCRI49:521 sit( Orders 4 :rO 22369 i <br />Ith"r Pr5w P PE <br />15. GENERATOR'S)OFFEROR'S CERTIFICATION: Hereby declare that the contents of this cb%ig mwl are fully and aoaratety desobed above by the proper shipping name, and are classified, packaged. <br />marked and labeled/placarded, and are in all respbcts in proper condition for transport aaordirlg„e applicable inlemational and national governmental regulations. if export shipment and 1 am the Primary <br />Exporter, I certify Ihal the contents of this consignment conform to the terms of the aftached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement iderdified m 40 CFR 26227(a) (f I am a large quantity generator) or (b) (dl am a smal quantity generator) is true. <br />Geaerators/Offerors Pmrtedffyped Name Signature Month Day Year <br />i <br />-i <br />i - <br />16. international Shipments <br />F1 Import to U.S'. ❑ Exportfrom U.S. Port of entrylexit--- <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. TransporterAcfmowtedgmenl of Reoe pt of Materials <br />Transporter 1 Printed/Typed Name Signature_ Month D Year <br />Transporter 2 Pr nted7typed Name Sign Month Day Year <br />gr <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Futi Rejection <br />Manifest Reference Number: <br />} <br />18b. Alternate Facif. <br />ity Generator <br />F- <br />or <br />( ) U.S. FPA ID Number - -- <br />J <br />U <br />LL <br />Facility's Phono: <br />L <br />t8c. Signature of Altemate Facility rty (or Generator <br />Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />12. <br />132 <br />3. <br />4. <br />20. Designated Facility Owner or Operator. Ct.rtifation of receipt of hazardous materials covered by the mandest except as noted in Item 18a <br />PnWdfTypod Name, - Sign=ro Month DD2Y Year <br />; - j> ` <br />"',r <br />1'AL ` r D 1 7 <br />cra runt orvu-44 tnev. wo) rrevrous eumom are olmtete. <br />y I <br />DESIGNATED FACILITY TO GENERATOR <br />