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Please print or type.(Form designed for use on eli a(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> i <br /> UN FORM HAZARDOUS 1.Generator ID Nu bar 2.��ency Response Phone 4.Manifest TrackingNumber <br /> WASTE MANIFEST `.•AU0154S,98289 s � , �2 2 JJK <br /> k <br /> L •,.J <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> CHEROKEE LA <br /> L Q 0 1, GA 952"t0 <br /> Generator's Phone: 209 335(&Xk <br /> 6.Transporter.1.Company,Narpe,, mbar. <br /> 1. '.,,_52 1105 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.De�t9n dA L 1Fac ItYNa a��Sit�e �drqss �-C. 1:,IJ I r __. .,_. _...�5._E�AgJ It bi S 4(�5 <br /> 3150 EAST' PTCI, BLVD. w <br /> LCIS ANGELES, CA 500 :, <br /> Facility's Phone: <br /> (8Q' ) 44 7LCL; <br /> ga 9b.U.S.DOT Description(including Proper ipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> � PGII, RQ, fiL,t�0�:1) <br /> i u GLJt <br /> Z 2. <br /> W <br /> t7 <br /> i <br /> { <br /> 3. <br /> j <br /> 4. <br /> 14.S Vial HandlingAn trupttiogs and Additional Info ation <br /> ��J1 t A, #� h:.44 <br /> GLOVES, GOGGLES & PR` TECTIVE CLOTHING <br /> ERG:4: Sib!) 1418 <br /> TRAiNSPORTEER 1. PHONE 1-800-752-4566 <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all resl acts in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consigr ment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> 1 certify that the waste minimization statement ide ntified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity,generator)is true. <br /> Generatods/Ogeror's Printed/Typed Name "Signature 'y -- Month Day Year <br /> , N' <br /> .j 16.Intemational Shipments <br /> I.- El Import to U. . ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials /'' <br /> Tran§porterYPrinted/Typed yaw* Signature / Morith Day Year <br /> Z Transporter 2 Printed/Typed Name Si riature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Residue Rejection " <br /> Full Rejection <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> o19.Hazardous Waste Report Management Method Cod (i.e.,codes for hazardous waste treatment,disposal,and"recycling systems) <br /> LU 1 2. <br /> I20.Designated Facility Owner or Operator;Certification f receipt of hazardous materials covered by the manifest except as noted in Item 18a_ <br /> Printed/Typed Name Signature Month Day Year <br /> ' <br /> Epp, ... - <br /> 8700-22(Rev.3-05) Previous editions are bsolete. DESIGNATED FACILITY TO GENERATOR <br />