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Hli� <br /> -" - _ ,.,�_. ... i.- <br /> sa � hAZAMUS paw,Lr 3[mergercy RMm� <br /> N 012177674 JJ <br /> iUIFORM f Genera��r ItJlVutt + <br /> WASTE MANIFEST (OflB t <br /> k 1�� Generators Site Address f f di"erent sear m3tteio address) <br /> 5.Gene la's Name and Ma ling Addressf+ <br /> 'gi3 L #y-ting <br /> L <br /> 13�d 1 • AJto,�o��11 <br /> Generators Phone: 7 Q U.S EPA ID NuMW <br /> F,.7r�tsDo rer 1 C•omVny Marne M <br /> 7 T,arsporter 2 Comtpany Name: <br /> U,S.EPA ID Number <br /> a.Deaignatad Facility Nate and Ste A&Iress e_ l_ ut1 CAL'n.,1,�-�) 00 <br /> U.S.EPA ID Number <br /> CA IR39 0 17 <br /> 9a. 9b U.S.DOT Descxipbw(including Proper Shippm�Name.hazard Class.ID Nurnbei, to.Containers 11 Total 12.Unit 13.1113ste Codes <br /> NM amPKimVGrotrrt(•Samr)I No. Type Gua try V1t.iJo. <br /> LY <br /> 3. <br /> A t x <br /> 14,Special q/+< Handling1and <br /> Irtt <br /> (,A 14ama <br /> 15. GENERATOR'SlOFFEROR'S CERTIRCATION.l h eby declare that lie contents of ns conaigmment are fuify and accurately descMed above by the proper shipping name,and are ciass&ed,packaged, <br /> marked and iaWEWpiacarded.and are m all respernslm most condition for ttartsport acmckng to applicable mtenational and national Bove-mental regirations.If export shiprneni and I am the Primary <br /> Enomr,.i certify Mat the eontents of thisconsit;incrtel corifonn to the terms of the attached EPA Acknowledgment of Consent. _ .. <br /> cerbfytrtat the waste n in mrzaUm stawmant dem ri GFR 2ti221ta);rf 1 am a large quantity'generator)or(b)(dl am a quanidy ge uxetor)s true. <br /> Generatre WI Pr ntedly home S gnatwe Madh Day rer <br /> .r 15.Mten atiUonal SN nz ��---tt <br /> J Import to U.S. L�Export from U S. of entrylexih. <br /> TrtnsFrorter sgratu a(for explore pnlyt: Date leaving U.S.: <br /> 17.Trawoirer AdroMedriOnt of Recegt of Matte <br /> 7 i PmledTjp2xf Name Signature <br /> Mordh Day rear <br /> a - <br /> ? tanspo 2 fttWTypW Name Srgnatu a <br /> Month Day 'rear <br /> 16.DiscrepaacY 1 <br /> 18a.Discrepancy+nocation8pace Ll Q'-MY LJ Type ❑Resitlue ((�—,1�t <br /> Partial Reject on LFull ReRebon <br /> - Manifest aelerence Number: <br /> IBM Atternate Paciiq(or Generator) - <br /> U.$:EPA ID Number <br /> V <br /> U_ FaoliYs Phone: <br /> M 1g,S brakce of Memate Facky(or Gereraw) <br /> Q I Month Day Year <br /> 2 <br /> h19,Hazardous Waste Report Management Medtod Codes f codes for hazardous waste treatment blsposel.and recycling systems) <br /> LU t 2. 3. <br /> Q l 4 <br /> 20.Designated Facitty O*rw or Operator.C.er9cation of nt of hazardous materials covered by the manifest except as noted in Mem,tea <br /> Ot1t1tP�Ty��2R1E SgnaNtO <br /> Month Dom, Yeats <br /> EPA Form 8700-22(Rev.3-05j:Previous editions at'Q nh to. DESIG@3hT1`"' -A ILit'Y`TO DESTINATION STATE(!F REQt11f3Eo� <br /> 0 <br />