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Please pnnt or type..(Forth designed for use elite 12-pitch)typewriter.) 1 r ` b1 ,: Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator I Number 2.Page 1 of 3.Emergency P&wnie Phohe 4,Manifest TraNumber <br /> WASTE MAN�EST 01604352 JJ K <br /> 5.Generators.Naroe and MarTngAddress Generators SEWMiress(if different than 1`1130+ng address) <br /> � 11y"W-7!Li:. <br /> P E} I�/9 CR 9136A 4840 N.`err,ar#wft Ave <br /> Gams Smsldlarl.CA 95M5 <br /> �:Tra�pa�r 1 Y►� U.S,EPA fD Number <br /> vttr0wva E1titBpr7r3 (:At_0C10sk86�b <br /> 7.Transporter 2 Comparry Name U.S.EPA ID Number <br /> t3.Dasigna.led Facility Namearxt, Address. U.S.EPA ID Number <br /> tmn <br /> Wast k.�ArltaT fief <br /> Fadlttys Phone M 1 711.-1-8-11111-1-�3 <br /> ga. 9b.U-S.DOT Description(erduding Strippkrg Name,Hazard Class,ID Number, 10.Containers 11.Tobi 12-Unit <br /> HM and Packing Group(if my)) No. T;d Quantity WtNd 13.Waste Codes <br /> 1- �., <br /> 352 <br /> p —. ..... <br /> z 2. <br /> LU <br /> 3. <br /> 4. ) <br /> t <br /> 14.Special Handling Instnxtions and Additional kiormation <br /> `1F�Q(052158 <br /> ICl <br /> 15, GENERATOR'SIOFFFROR'S CERTIFICA :I hereby declare that the contends of this camignmerlt are fuly and accurately described above by the proper shipping nerve,and are classified.packa9ed• <br /> marked and Wbalodlplacarded,and are in a0 proper condNbrt for transport according to appficahYa International and national goveminaft regulations.If Oport s ipirrent and I am the Primary <br /> E porter,I cartiy Mthe contents of this�n t conform to the terms of the attached EPA AclonowWwent of Consent. <br /> I certify that the waste minimization statemen kknOfied In 40 CFR 26227(a)(d I am a large quantity generator)or(b)(f I am a small quantity genaralor)is true. ^ <br /> Generators/Otierors PrinfedlTyped Name Signature fdonfi Dayy� Year <br /> :,:'1:t�.',?.9 rE7e'.fr1�i - l IJ-'N /� /�+� r.+f• <br /> 16.International Shipments <br /> Impont U.S. ❑Export from U.S. ontrylex t: -_-- -- -- - -- <br /> Transporter signature(for exports only: Date leaving U S.: <br /> w 17.TransporterAdawwledgmerdof Receipt of Matenals <br /> Transporter 1 PrhttedfTyped Name Signature !`� tdonth Day Year <br /> � r — <br /> ZQ Transporter 2 Pdntedgypbd Niime Sigo9hre Morth Day Year <br /> 18.Disctspancy <br /> 18a.Discrepancy Indication Space E] Qua ty u Type Res due Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate facility jor Genefater) _ U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of ANemate Facility(or Generator) Monty Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Madrod (ie.,codes for hazardous waste treatrnant,disposal,and recycling systar s) <br /> 0 1. � 2. . 3. 4. <br /> 1 <br /> 20.Designated Facility Owner or Operator 'Ce n of recta of hazardous materials covered by the manifest except as noted in Nem 18a <br /> Prmtedrrypgd Name I Signature Month ay Year <br /> EPA Form 8100-22(Rev.3-05)Previous editions Ara-obsolete. J ICMSIGNMi ED FAcILITYTO GENERATOR <br />