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v, - �.... <br />Please print or type. (Form designed for use Ion elfle (12 -pitch) typewriter.) , <br />tom: <br />C...... A .............! il�Io � n nn7n <br />UNIFORM HAZARDOUS <br />1:.C�neratoq ID Number <br />2 Page 1 of <br />3. Emeigenq Respotue Phone <br />4. Al ilesf 7 .._.._..�..(_ <br />WASTE MANIFEST <br />1M15J <br />J <br />Ail if 17x1 <br />[` <br />5 Gelds Name and Maddtg Address - s ft-Qf dfierent than mailing address) <br />f � 41Ds1�le�t1.1.C. <br />$Ctc 33M 1W 1f. air Ave <br />C' 5+&1. CA $93$d <br />Generdots f CA 9522M <br />6. Trawpader 1 Gxw"uslie <br />U.S. EPA ID Number <br />&id1R!ft <br />t_ Q? <br />7. Transporhx 2 Company Naive <br />- <br />U.S. EPA ID N4mtber <br />fadtig'Neniearct5pe• <br />C�►±+6�+rs Bl.�rt�rnit i i� <br />U.S.EPAID=. <br />2'S4?kT >�ikEr.�ry Psi <br />C�F37577tT <br />Fad61y's Phone: <br />9a. <br />9b. U.S. DOT Description (nciudng P Impar Shipping Name, Hated Class, R)Number. <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No <br />Type <br />HM <br />and Paddng Group (d any)) <br />Quantity <br />WLW <br />1. T 4`i izr 42n ! rtO*c� t:'a S'F ate!?;+,J N CW*N*4t0d Debris) <br />P <br />352 I � <br />Z <br />2: <br />LU <br />7 <br />3. <br />i <br />r <br />4. <br />" <br />1 <br />} <br />14. Special Handrmg Inst urban and Addftnai information <br />_ j <br />15. GFNERATOR'SIOFFEROR'S CERTIFIC ON: I hereby dedare that the amtents of this rgn9gnment are fully and accurately described above by the proper shipping name, and are lass& -d, packaged, <br />:.: <br />in proper conon for transport aaordinrglofappGcable iMemational and r atiorrai govenxnenial regulations. if export shipment and 1 am ate Primary <br />marand labeled/placarded, and are in l ddi <br />ked <br />Exporter, I certify that the contents of ftn%gmnent conform to the twins of the attadied FPA Aclumledgrrnent of Consent <br />I certify that the waste mKwTuabon s idehMied in 40 CFR 28227(a) (d 1 am a large quantity generator) or (b) (d I am a tity genxxalor)'s true. <br />GeneratorslOflemr's Prinfe&Typed Nam I Signature <br />Month Year <br />++Day <br />116. <br />;- <br />Irntematonal Shipments <br />❑ Impeo to U.S. ❑ Export from U.S.of entry/exit <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />LCC <br />17. TransporterAdmowledgrnefd o( Receipt of <br />Transport 6t4alWITyped Nave— .I -Signal llee <br />Mordh Day Year <br />Transporter 2 PrintedlTyped Naive Y / <br />4s <br />Month Daisy Year <br />F <br />I <br />18. Discrepancy <br />18a. Discrepancy Indication Space ry�n6ty F-1 Type ❑ Residue <br />T <br />❑ Partial Rejection <br />❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />U <br />LL <br />Faciktys Pt one. <br />Lu <br />1 ac. Signature of ARemate Facility (or Generat>r), <br />Month Day Year <br />Q <br />2 <br />N19. <br />Hazardous Waste Report Marnagernent Me Codes (i.e., codes for Ir�dotrs earls treatment disposal, and recyr5ng systems) <br />pLLI <br />1.2 <br />1-1J3� a <br />3. <br />4. <br />20. Designated Facility Owner or Operator Cerbfi of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />S <br />PrtntenilTyped Name - � 1 `., 1's . -Signature� <br />Month Day Year <br />V ' t 1 <br />LPA Form 67UU-2z (Hev. 3-05) Previous eaMonj are onsolM. / CepSIGNATEID FACILITY TO GENERATOR <br />