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Please oridFor tine (Fnnn dP..CI iPA fnr use u PUta i72_nitrfit ivrwvaitar 1 <br />Form Annmved OMR Nn A.ri0- '. <br />1:FA roan tuUU-ZZ (Rev. aa15) rrevau9 eomonspre onsofete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />._ `gator D Number <br />2 Paga 1.of <br />3. Emergency Response Phone <br />4: "if Tra - <br />WASTEMANIFEST <br />016 317 JJIK' <br />rweISre <br />- <br />5 CxalerdEor s Name and MalfingAddress . - Genera s (d ddfinenl than ma ng address) <br />i' <br />t F�#i RRf�17�Tfi..LL�s. <br />, <br />Iwo N ftactA W A-49 <br />CA 95m, <br />a iter 1 Cdorpavme -`_ ll.S. EPAID Nimiber ' <br />7. TranVorter 2 Company Nater U.S. EPA tD Number <br />8 Oe�pit�edFaa Nanearirl eAddress' <br />U.S EPA ID Number <br />1 LWasrn3 rAt19fD/1S7S27 A <br />Fac4ltr/s Phone: <br />92: <br />9b. U.S. DOT Desaip6on (hndtMig <br />Stinppeg Name, Hazard Class, ID Number, <br />10. Cordaioers <br />11. Total <br />12 Unit <br />13. Waste Codes <br />No. <br />Type <br />HM, <br />. and Padang Group (dant)) <br />Quantity <br />WUVa <br />1 't:i r?!;i=t+ F;rc k�°atsiz �;< i i rtnt•itx+ Iehrs }. <br />Cm <br />s <br />zLU <br />2 <br />i <br />— } -- <br />3. <br />I i <br />4. i <br />1 <br />1 <br />14. Special Handling Instructions and Additional <br />4•.ta#471(F-W1:4'<�' <br />Awprow.. P,P-E. <br />i <br />15. GENERATOWS10FFEROR S CERTIMA <br />ON: I hereby declare that the contents of this toys gnmert a e fully and acaaately described above try the proper shipping name, a d are classified, padra9ed, <br />marfned and tabeledfptacarded. and am in 4 <br />respects in proper condition for transport acco dinrg.#oapplicable international and national governmental reghdafions. K export shipment and I am the Primary <br />Exporter, I certify that the contents d ttas <br />oadonn to the terms of the attached EPAAdTorMedgment of Consent <br />1'oertify that the waste minimeat on sta <br />t identified in 40 CFR 26227(a) (if I am a targe quw* generator) or (b) (dl am a quantity generator) is true <br />GeneratorsOfferoes PdntedfTyped Name <br />Signore Month Day Year <br />Tt� f <br />og a ; <br />—1 <br />16. international Shipments:, <br />E I U.S. Ll Fort from U.S. Port of enbylexd: <br />Trarisportar signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter kknowle)-ameiofReceipt of <br />r" <br />0 <br />Transporter 1 Pmte&Typed Name Signature �'7 Month Da Year <br />�''7+7 <br />QTransporter <br />2 Pnrdedfryped Name % S g Month Day Year <br />F <br />18. Dsaepancy <br />18a. Discrepancy hbication Space El oufny Type ❑ Residue ❑ Partial Rejection ❑ Full Re)ection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generalor) — -U.S. IPA ID Number - <br />J_ <br />V <br />pax <br />Faalitjs Phone: <br />W <br />18c. Signature of Alternate FaaTAy (or Generator) <br />Month Day Year <br />Q <br />; <br />Z <br />CD <br />ingUj <br />19. Hazardous Report Management Codes (ie., codes for t�ardors waste treabnenk dial, and recydug syste(rrs) <br />Waste <br />1 0 1 3 2 <br />2. <br />3. <br />4. <br />20. Designated FacJrty Owner orOperala Ce of raceipt of hazardous materials covered by the ma dtest except as noted'm Item 18a <br />Printed)Typed NameSignabxe Month Day Year <br />"�-, r .Ll <br />'A'e- , <br />1:FA roan tuUU-ZZ (Rev. aa15) rrevau9 eomonspre onsofete. DESIGNATED FACILITY TO GENERATOR <br />