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Please print or type. (Form desioned for use on elRe (1L -.itch) tvoewriter.) <br />17— Ann —A r)1AR Aln 9n5rLfN190 <br />Cr -m rrnnl oivv-" trCev 3-u7) Previous entmons are o"ete. <br />s <br />DFx1SIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID NumbeA <br />2. Page 1 of <br />3. Emergency Response Pt one 4: <br />WASTE MANIFEST <br />I i -,u eau <br />016M�15 V �, ` . <br />5. Generators Name and Mailing Address fig s (tdienent tlran mailing address) <br />�Mw"www*LLC. <br />� gx <br />Gemaioi s . � <br />6. Transporter t Cwpiny Marne U.S. EPADNumber <br />YrOusim Thi c1i�_4E�11 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />$ ldFNanie audSite` <br />a,.� <br />IC - <br />1111111111110 W10W, CA 93M <br />ga <br />9b. U S. DOT Desapnn (rndrdrg Proper Stippng Name, Hazard Class, 1D N miber, <br />10. coma hers <br />11 Total <br />12 Unit <br />HM <br />and Padang Gro4 fdany)) <br />Otrarrtily <br />Wt Nd. <br />13. Waste Codes <br />No_ <br />Type <br />Civil <br />P <br />62 , <br />i <br />3. <br />( <br />r <br />4. <br />j <br />14. Special Handling Instructions and Additional Information a <br />�� # 3 !i � � #•ii 13�!�2'T�i � � <�rtbr;<k 17(1392) _ _ . <br />15. GENERATOR'S(OFFEROR'S CERTIFICATION: I =by declare that the contents of this con ' nrneM are fully and acauately described above by the proper shipping name, and are classified, packaged, <br />maAted and labele#lacarded, and are in all respects in proper condition for transport accordinlgapplicabie international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the temis of the attached EPA Aclmowk igmerd of Consent_ <br />I certify that the waste minimization statement &-b0W in 40 CFR n2.27(a) (d I am a large quantity generator) or (b) (if I am a nfity generator) is true. <br />Generatoes/OHeors FnritedlTyped Name S gnature Month Day Year <br />ih lief fdan; Lk �, 1 <br />i <br />16 Infefnaliortal Shipments Import to U S.❑ Expo t from entrylex <br />Transporter signature (for uxports only): Date leaving U.S.' <br />W17 <br />Transporter Acknowledgment at Receipt of Materials <br />Transport yped Name„_ Senahue —_? Month Day Year <br />C <br />In <br />8 I )I <br />Transporter 2 Pnnted/Typed Name Month Day Year <br />18. Discrepancy <br />, 8a. Discrepancy Indication Space Quantify Type Residue ❑ Partial Rejection 0 Full Rejection <br />Manifest Reference Number. <br />18b. Altemate Facility (or Generator) - U.S. EPA D Number <br />J <br />V <br />LL <br />Facility's Phone: <br />W <br />Q <br />IAC. SlgnaNfE or AH—'u: F»city (w Crn,c.atnr)D Yea <br />Z <br />19. Hazardous Waste Report Management Method Codes (i <br />i.e., codes for hazardous waste treatment. disposal, and recycling systems) <br />ui <br />t 0132 <br />2 <br />3 <br />4. <br />20, Designated Facility Owner or Operator. Certification of r X20 of hazardous materials covered by the manifest except as noted in Nem 18a <br />Prinledff" Name <br />1 4 Signature Month Year <br />ii I /Day <br />Cr -m rrnnl oivv-" trCev 3-u7) Previous entmons are o"ete. <br />s <br />DFx1SIGNATED FACILITY TO GENERATOR <br />