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• Ii <br />Please print or tyDe. (Form desjaned for use on elite 11 p-nitcht tvmmnter l <br />V— e u —4 nun Axn 'MrA-AAQ0 <br />EPA Form 67OU-22 (Rev. 3-05) Previous earuons are onsotete. DESIGNATED JFACILITY TO GENEHATUH <br />UNIFORM HAZARDOUS. 1. Genera6or ID Num!>� .. 2. Page 1 of 3. kiergencyIhlatidest Tracking Number <br />WASTE MANIFEST <br />14 7016674352JJ K <br />CAI <br />5.CieneratoCsNtwandMaftAddrens s (if diflerentthanmailing address) <br />�tt�Lifi- <br />GrA <br />�lllildlr CA 91394 <br />Gei�aiod`g <br />Tralspor�ri U.S. EPA ID Number <br />T. 7ransporter2 Company Name U.S. EPA 10 Number <br />2W0r.!!IRd CAQM75M <br />CA DSM <br />Faciflys Phone: Mti-%62- <br />ga <br />9b. U.S. DOT Desapbon {ndudi g Proper Shippjrg Name, Hazard Class, m Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste, Codes <br />No. <br />Type <br />HM <br />and R-ki"g Group (d any)) <br />Quantity <br />WUVol. <br />o <br />1. R r- RA f rtk=V �(*3(F yowD ) <br />t <br />CM <br />T <br />352_1.___? <br />W <br />M <br />2. <br />LU <br />3. <br />i <br />4. <br />t <br />i - <br />i <br />14. Special Handling Instructions and Additional i <br />FRG# M VYttf fTP.M E. fit' * 1d9521 - <br />15. GENERATOR'S/OFFERORS CERTIFICATION: 1 hereby declare that the contents of this crosignirnery are fully and accurately described above by the proper shipping name, and are dassfied, packaged, <br />marked and fabefedlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I cerfiy that the contents of this cons" conform to the terms of the attached EPA Acknowledgment of Consent <br />I certify Ilial the waste wlink�atim statement identified in 40 CFR 262.27(a) (d I am a large quantity generate or (b) (if I am a small quantity generaia) is true. <br />GeneratoeslOfferoes PrWed/Typed Name Signaiufe l� Month Davy Year <br />.:E°j�Ti t`_iXS:>l�C�iitt LA /cif f <br />1 of r- (✓ <br />=j <br />Z <br />16. International Shipmentsrr� <br />❑ Import to U.S_ LJ Export from U.S.entrylexiL ---- -- --.—. <br />Transporter signature (for exports only): ate leaving U.S.: <br />17, Transporter Ackrrowledgment of Receipt of Materials <br />Transporter 1 PrintedlTyped Name Signahtre ! Month Day Year <br />za <br />Transporter 2 Pwled/TypW NaM S ane Month Day Year <br />r- <br />18. Discrepancy j <br />rrll <br />18a. Discrepancy Indication Space Ouathtity Type L__! Residue ❑ Partial Refection Full Rejection <br />Manifest Reference Number. <br />18b. Aftemate FarAly�or Generator) J U.S. EPA ID Number <br />U <br />Facifrtys Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />h <br />19. Hazardous Waste Report Management Metrecycling Method Codes (ie., codes for hazardous waste treatment, disposal, and recling systems) <br />O <br />1. <br />2.. 'li <br />3- <br />4- <br />20. Designated Facility Owner or Operator. Certifxation of receipt of hazardous materials covered by the mantFc-,3t except as noted m Item 18a <br />Nnted(f N2R12 I Signahlre Month Day Year <br />EPA Form 67OU-22 (Rev. 3-05) Previous earuons are onsotete. DESIGNATED JFACILITY TO GENEHATUH <br />