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Please orint or tvDp (Fnrm dP.qinnPA for imp nr P&P. 11 9�itnhl tvrwwrif- I <br />DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator llIN6mber <br />2 Page 1 of <br />11 <br />3. Emergency Response Phone <br />- - - - - - - - - - <br />4. Manifest TrackinlNumber <br />1 <br />MANIFEST IFEST <br />AMR <br />0166 4316 JJK <br />-- r- Guatoes SiteAftess (d different than mailing address) <br />5. GeneraWs Name arid Wging Address' ffl 5, 1" <br />V, <br />49 milk t - <br />7 U& EFAIMwah.; <br />CALINM I SAS <br />7. Transporter 2 Company Name U.S. EPA 10 Number <br />U.& EPA 10 Noritiar <br />MW kae <br />*c . <br />— -- <br />io DON <br />Ihjftw*&W, CA OM <br />ga, <br />9b. U -S- DOT D-#Wn *Wkliing Purger Sho*q Mane, Hazard Vass, ID Nunke4 <br />10. (�(biners <br />11 TOW <br />12 Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and PacAkQ GMMOf OWN <br />Quantity <br />WLAU. <br />Rr' P Hazirlm" W7lF 7P SA)WI, CWftTKL**d Debft) <br />-CM <br />0 <br />;r <br />2. <br />Uj <br />3. <br />4 <br />14. Special Handling Instru.clions and Additional . In f.tion <br />ERG# t7l ( PrU11111le"U9621 Order # <br />V41W PMW P.P R <br />15. GENERAT01USKffM0lrS CERTIFICATION: I hereby declare M the contents of this consignment are fully and acuratety described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all r6spects in MW condition for transport acoonlingJb.ap;plicabie intemationa] and national governmental regulations.. it export shipment and I am the Pnrnary <br />Exporter, I car* that the contents of this cwv*jrLrnent confirm to the terms of the attached EPAAclomyledgment of Consent <br />I certify that the waste ninimLtion statement6dainfifled in 40 CFR 26227(a) fit I am a large quantity generator) or (b) (d I am a small quantity generator) is true. <br />GeneratDesK)fferors PrintedfTyped Name SignalizeMonth Day Year <br />JeiyD Karlids" 6. <br />16. Inletnational Sbipmwts <br />[I Import foU.S. DExport from U.S. <br />Transporter signature (for exports, only): Date leaving U.S.: <br />W <br />17. TransporterAdurowiedgment of Receipt of M" <br />W <br />Transporter I Pdn*Vyped Name &gnature7 Day Year <br />W <br />0 <br />CL <br />1 1 r� 1 13 <br />1 <br />(n <br />:= <br />–Da <br />Transporter 2 Printe(gyped NameMonUi y Year <br />Ix <br />18. Discrepancy <br />18a. Discrepancy Indication Space 0 OLn� 11 Type 0 R.W. ❑ Partial Rejec ton [:IFul Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (of Generatc)r) U.S. EPA ID Number <br />rai <br />Facility's Phone: <br />180. Signature of Alternate Facility (or Genera" <br />Month Day Year <br />z <br />19. Hazardous Waste Report Management Method i.e, codes for hazardous waste treatment, disposal, and rftycltrq system) <br />--T <br />4. <br />20. Designated Facility Ow of receipt of hatzardous maWials covered by the man fest except as noted in Rem I Ba <br />Printed/Typed NameSignakire Month Day <br />-9 i I <br />e, 1 r221 <br />DESIGNATED FACILITY TO GENERATOR <br />