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..::. <br />s'iC'``:c ,:: -`•::':iii - - - - = - :ti7•� _,�ti �.>•., ,_ >:_>�_'�; 3w: tint :: �: �r:=='`::a_=-'--w =�'s- =__ �ai�•_ <br />Form Approved. OMS No. 2050.0039 <br />please print or type. (Form designed for use o181.1113(�2"pltCh) ) 2_ Page 1 of 3 F-roergerIcy Response Phone 4. Manifest Tracking Number _.. � � _ J <br />1. Generator ID Number }L'�i. <br />UNIFORM HAZARDOUS i rq i# -Sv: ®� 3 0 915 <br />WASTE MANIFEST C A ` O Os � a T <- r Generators Site Address ('f different than marling address) <br />5. Generator's Name <br />l and Mailing Address <br />HOLT�t_� ` <br />ST� O- <br />- 4CH'c_ 'O7cKL nw Wr'.Y CA E0520G <br />SARA- MEN TO �001 U.S. EPA ID Number <br />Generator's Phone:�yv <br />6. Transporter 1 Company Name C .A 0 0 2 8 2 7 7 S 9 <br />rrc FaeinNumber <br />~ffl�a sATTt' it�#`�rfys <br />. s =yt r s' E I'E <br />ail ;.,,His r E .s fti; 2 <br />LOS ANGELES (` a rm <br />Fadlty's Phone: (SO:126 -7 + 47 <br />on mcludi Pm ShippingName, Hazard Class, ID Number, <br />9a, 9b. U.S. DOT Desvipti C ng Pei <br />HM and Pecking Group Cr any)) <br />0 <br />W <br />z <br />LU <br />3. <br />U.S. EPA ID Number <br />A11)0970305393 <br />10. Containers 11. Total 12 Unit 13. yktasts Codes <br />No. Type QuarrtitY Wtivol. <br />_30o <br />t <br />14. Special Handling Instructions and Additional r rarmaakxr �T a` - <br />e;-. i 9—;1 r S ! � "` :f %�(a1_fuC� E CONT (A . C ,E <br />f a:C,l+. ,:eT .:rte Atr� �-�-�ti r4rf�['. fs�aiiES : 6 `L� ` ��r �/ �` — G7�fiv't- <br />�'f'.P''i�:,.'�'es�S"'r LT.+.F t�L•yl�•4•_•� �� <br />i E —'4 F �rt...-r_ _2 .- <br />r i F �E AJ 1PatFE T 1 i1�� the proper shipping name, and are classified packaged. <br />PRC-``� • are ful and auatrately described above by prop RP 9 <br />15. GENERATOR'SfOFFEROWS CERTIFICATION; I hereby declare that the contents of this consignment Y ns. If export shipment and I am the Pdffk-0 <br />marked and fabefedlpiacarded, and are in all respells in proper condition for transport accord"g to apprmable intemafional and national govemmerdal reguletio <br />ant rd Consent <br />F�kportar, l rzrtiiy that the corttenb of this consignment conform to the terms of the attached pAAdmovror (b) I am a smal quantity generator) Is true. Monfi Day Yea <br />I certify that the waste minimbation statement idenSW in 40 CFR 2$227(a) (if i am a large quantity generator) <br />Gane ' r's108eror's PrintedlTyped Signature <br />❑ <br />F- 16.1ntemational Shipments [Ijr <br />Import from U.S. port of antrylextt Import to U.S. Data ieaving U.S.: <br />a Transporter signature (fir exports only): <br />Ye <br />w 17. Transporter AcknoWedgment of Receipt of Materials Sigrab- <br />Month flay <br />i Trarsportes4rinted(lyped! r - l�1. vi_ % I — <br />th L <br />MonDay Yk <br />VA <br />18. Discrepancy <br />18a. Discrapancy Indication Space Quantity ❑ Type <br />18b. Alternate Facility (or Generator) <br />V <br />Q F duty s Phone'. <br />LL. a <br />18c. Signature of Alternate Fedltly (or Gernerati;4 <br />disposa andd <br />CD <br />Z <br />19. Hazardous Waste Report Management Method Cedes (t.e, codes for hazardous waste treatment, ------- r__ <br />1 2 <br />20. Designate a 'lily 0 or Operator. Certification <br />prntedlTyped Name <br />EPA Form 8700.22 (Rev. 3-05) Previous tons are <br />❑ Residue <br />covered by are manifest except as nded In Item <br />DESIGNATE <br />❑Partial Rejection ❑ Ful Re}ection <br />U.S. EPA ID Number <br />A, <br />TG L'EE i INAT ON STATE (IF REQU <br />