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Pleasenot or pe {Form designed for use on elite(12-pitch)tVpewrner,j Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS IGenerator ID Number 2.page 1 of 1 Ema nq Response Prone <br /> 4Manifest TrackITrackingNumber <br /> WASTE MANIFEST o 1JI'M" <br /> l <br /> ("5 S K S- <br /> 5,Generator's Name and Mailing Address Generator's Site AfteSS(if different than rnailxV address) <br /> i ii CA <br /> GeneratDr%Phone: 4 iaG,3 2 <br /> 6.Transpafer I Company Name <br /> U.S.EPA 10 Number <br /> T.Tr8nSI 2 Company Name U.S.EPA 10 Numee, <br /> 8.Designated Facility Namt,and Site Address CLEAN H�4'13BORS ;3p"4 jf]SjE I C US,EPA ID NwVer <br /> FacGl CA 95133 <br /> P <br /> ; N—S!DOT Description(including Proper Shipping Name,Hazard Oass.ID Number, to.Containers 11 T.w <br /> HN4 and Packing Group any)) 12.Unit 13-Waste,Codes <br /> Na Cunn1iry "JVOI, <br /> id <br /> uj <br /> z Z <br /> 4, <br /> REGEIVEL, <br /> MAR 27 2015 <br /> 4. <br /> ENVIRONMENTAL <br /> HCA'-u")=60TRACKIT <br /> 14,Spec aI Handling Inst—NCT <br /> OAS and Additional Information <br /> 15 GENERAT'OR'SIOFFEROR'S CERTIFICATION:I hereby dadamft the cOnletrIS Of this I Consignment are fully and scojrately described above by the proper Shipping name,and are classified,packaged, <br /> marked a-ld labeleftlaurdod,and are in all respects in proper wMition for transport according to apiplicabie international and national governmental regulations.If export shipment and I am the primary <br /> Exporter.I certify IW the contents Of"10;COntsignment cOnfOrm to the Iftrft of the attached EPA Acknowledgment of Consent <br /> I oe*that the waste min,mvalton statement Identified in 40 CFR 262.27(a)Of I am a large quantity generator)or(b)(If I am a smaj quantity generator)is trace'. <br /> Generatoestofferors Panted Typed Name <br /> Signal ae <br /> Month Day year <br /> JE <br /> 16.1 <br /> riternationwShipments F1 Import 10 U S. ❑Export I.,,U.S, Port of entrylexiT <br /> Transporter signature(for exports only): <br /> Date leaving U.S.: <br /> Uj 17. <br /> T nsp-In'erAcknowWgwlofRemplof&iat-rals <br /> TrarSPOISr IPdnted(Typed Na <br /> 0 Signaturo Day yf?'Ir <br /> Z T=r -'�Nn*VypedN&ne <br /> < 5ignatifffi Mn.n!h Day ',�ar <br /> ti <br /> 18,Discrepancy <br /> Ina-Discrepancy Indication ioatlon Space Fun Reject; <br /> R QuaRes due L]Partial Rejeuion an <br /> 18b.Aftemata,Faciltity,(or Gelw&4 <br /> Manifest Reference Number U.S.EPA 0 Number <br /> LL. FAcilitys Phone. <br /> 18c Signature of Afternote Fadlity(or Generator) <br /> 4101th Dw, Y'ts:r <br /> 19.Hazardous Waste Report Management Method Codes(e.,codes for hazardous waste treatment,disposal,and fft-yc!kV systems) <br /> 1. 1W i <br /> 73. <br /> 20. - <br /> 'esigrated FaQff[y Owner of Operator.CertftalfDn Of receipt of hazardous materials covered by the manft except as noted in item 18a <br /> Affilf I YPea Netne <br /> tuns Month --NN—Yp� <br /> EPA Form 8700-22(Rev 3-051 Previous edit ins arc ol),zolptf. <br /> DWGNAT ED FACILITY T'Q QENERATOR <br />