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Please print or type, (Form designed for use on elite 22 itch typewrRer.) <br />--PA Form 3 -GO -22 (Rev. 3-05) Previous cclitions are obsoleie. DESIGNATED fAQLITY-$ COLPY <br />I-OrM APPrOVM. UMU No 2050-0039 <br />t I UNIFORM HAZARDOUS 1. Generator ID Number =Dage 10f 3. Emergency Response phone 4. Manifest Tracking Number <br />WASTE MANIFEST I , 1 r f <br />I <br />-N L -q <br />d <br />1 0 U -511 29 JJK <br />5. Generators Name and Mailing Address <br />LT"T (�enerator`s Sil!�ddress (if cIftent than mailing address) <br />( <br />154 <br />Generatoes Phone: X-9 11 "13- ,5-11 2 E703LTWICN 1-524 <br />6. Transporter I Company Name U.S. 10 Number <br />7 Transporter 2 Company Name U.S. EPA ID IN, mber <br />8. Designated ffilft,Name and SteAddress <br />U.S. EPA ID Number <br />Facill, (s Phone: A T 0 a 0 4 1 3 j .j <br />98. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />0. Cortairerstal <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Qu anuty <br />WLAtd, <br />13. Waste Codes <br />Type <br />0 <br />4 u1A 441 & 44 y !"J� czrlli <br />9 <br />THIS WASTE STREAM HAS BEEN QUALIFIED <br />FOR RECYCLINGrETREATMEFff AT THE <br />DeMENINO/KERDOON FACILITY NN COMPTON, <br />CALIFORNIA. THIS FAVLITY HAS THE NECESSAR) <br />4. P E. RM46 TO REGEIVE 1�4-314.4 ltS�F- SiRFAM AS <br />[14. <br />QUALIFIED! OUR EPA NUMBER IS CAT080013352 <br />Special Handling Instructions and Additional Information <br />15. GENERATORISIOFFERORISCERTIFICAT*N; I hereby declare that the contents of this consignment are fully and accuratgiy described above by the proper shipping name, and are classiped, packaged, <br />marked and labelediplacanded, and are In all respects In proper condition for transport according to applicable international and national governmental regu!adons. If export shipment and I am the Primary <br />Exporter, I certify that the cortents of this consignment conform to the term of the attached EPA Admowledgment of Consent. f <br />I ce" that the waste minimization statement Identified in 4C CFR 262.27(a) (if I am a large quarifty gerieralv) or (b) Cd I am a scrilill quantity generator) Is true. <br />GeneraWsiOlfWs Printed/Typed Name Signature, MOO ar <br />Day Ye <br />-Z <br />I D I I &v <br />ill. international <br />J <br />F— <br />Shipments <br />❑ imp., to U.S. ❑ Export h. U.S' Port of antly/will: <br />Transporter signature tfor exports only).- Data leaving U.S.: <br />L W <br />U <br />17. Transpwo Acknowledgment of Receipt of Materials <br />Transporter I PnmadiTyped Nam Mono Day Year <br />0 <br />.1 <br />Trans" 2 PrintecifTyped Name <br />Month Day Year <br />IY <br />18. Discrepancy <br />pa icy <br />am -y Ind <br />184. Disctep : Indication sPw* El ou." ❑ Type 0 Residue E]Parlial Rei.*, ❑ Full ROW011 <br />: <br />- ) <br />Manifest Reference Number, <br />18b, Altemata Fac!00ty for Generator) US EPA 10 Number <br />> <br />--81cf1it Y'S Phone. <br />U, <br />18c. Signature of Alterrate Facility (or Generator) Month Day Y--- <br />19 HaxafllousWaSte Report Management Method Codes (I a,, codes for hazardous waste notrnerit, disposal, and recycling systems) <br />LU <br />2. <br />20. <br />2 <br />Desigrarred F <br />W F lity Owner or 6wafor on of receipt ofhazarwmsmaierials covered by the mantles! except. asnicled -n ifent 'Be <br />Prin!" 1 yped Plarre 941"arture Mono Day Year <br />1/ 2 17 Z V <br />--PA Form 3 -GO -22 (Rev. 3-05) Previous cclitions are obsoleie. DESIGNATED fAQLITY-$ COLPY <br />