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ala��o nr .mono 1Fnrm A—innnri f--. nA n14n 119-4'M t --it., 1 f i i a .. Fnrm Annrnved _ OMR Nn 2050-0039 <br />EPA Form 870022 (Rev. 3-05) Previousest are obsolete.; IDES RGt.IAi* D FACILITY TO GENERATOR <br />�� <br />UNIFORM HAZARDOUS <br />1 gator ID Number <br />2. Page 1 of <br />3. Emergency Pikponsse Phohe 4. <br />Ala <br />''r��tifest T[r►acking Number �/ <br />01 � 7 2 JJ K <br />WASTE MANIFEST <br />"f 135 <br />5. Generators. Name and MaimgAddiess Genera s 5 mss (if different than maWN address) <br />:ss t'9ls, CJS 91394 4+30 3 <br />CerleratofsPhoner;in- SWCWn. CA 95M <br />6. Transporter 1 Company Name U.S. EPA fD Number <br />.rrtury ?:1 3j]fYi L34tt; <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated -Facility Name and -Site Address <br />US. EPA ID Number <br />Wk We -A L -* *-n Rt It �i�ri£ $75278 <br />A:4-mn--m4%tlr. <br />CA <br />Fadiify's Phow. i 1 7 a kTj( <br />9,. <br />9b. U.S. DOT Description (ruching Pn <br />W Shipping Name, Hazard Class, ID Mimber, <br />10. Container <br />11- Tota'. <br />12. Unit <br />13.41aste Codes <br />No. <br />Type <br />HM <br />and PsckiN Group (tarry)) <br />Q-117ty <br />WtNol <br />ir <br />1 - r's•;r1Ss`t3fFlCfilSfiS,` <br />w <br />0 <br />3- <br />4 <br />4. <br />14. Spe dal Handling In&ucbDns and Additiona I Information <br />tau ' i >;'r5'?!= f 3C#i otsa �?lftr3 i� it i � .'�� i � — — <br />15. GENERATOR'S(OFFEROR'S CERTIFI TION: I hereby dedafe that the contends of this consignment are fully and accurately described above by the proper shipping name, and are class .-ed, packaged <br />marked and labeledlplacaded, and are ffil. all respects in proper condition for transport accordng to applicable international and national governmental regulations. If export s4pment and I am the Pnmary <br />Exporter, I certify that the contents of this 0onsignment conform to the terms of the attached EPAAdvawledgmenf of Consent. <br />1 certify that the waste minimization stalenierit identBed in 40 CFR 26227(a) (d I am a large quantity generator) or (b) (if I am a small quantity generator) is true. - <br />Generahors fl rots PnnteM'yped Name j Signawre Moorrb Day Year <br />—>t <br />F— <br />16. International Shipments <br />❑ I to U.S. ❑ <br />Z <br />Export from U.S. eri'Wemt <br />Transporter signature (for exports onty): ;e leav ng U -S.: <br />17.Transporter Adamwledgment of Reoeipl of <br />Transporter 1 Ih rNad(fyped Name Siwtaaue / i MorO Day Year <br />IL <br />ZZ <br />Transporter 2 Printedriyped Nam Sigg re Month Day Year <br />r <br />18. Discrepancy r.. <br />18a. Discrepancy Indication Space <br />ntity ❑ Type ❑Residue ❑Partial Rejedan ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facilitylor Generator) L'.S. EPA ID Number <br />J <br />- .. - <br />U <br />LA- <br />Fadlity's Phone: <br />w <br />18c- Signature of Alternate Facility (or Generafdr) <br />Month Day Year <br />Z <br />U <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardousdisposal, and ciin ms <br />waste trearnenl, req g systems) <br />LU <br />1. ± _� <br />2... <br />3. <br />4. <br />t <br />20. Designated Facility Owner or Operator Cei fficatiDn of receipt of hazardous materials covered by the manifest except as ndW in Item 18a <br />Prirded(T)Red Namei I Signature Month Day Year <br />1 <br />EPA Form 870022 (Rev. 3-05) Previousest are obsolete.; IDES RGt.IAi* D FACILITY TO GENERATOR <br />�� <br />