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;(Fon*.�. ,gip, �.. l^ gOtbr.type. signed for use on elite (12 -pit ,ewriter ) r AuT+ VQ 709565 Form Approved. OMB No 2050-0039 orn rums orvu-u ,rtev. o-ual rrevmus eumons are oosoiece. DESIGNATED FACILITY TO GENERATOR rot ORM HAZARDOUS 1 �Num r/loo i 2. Page 1 R 3. Emergency Response Phone 900 �63 371d 4, Manliest Trackiling Number 000894521 C C WASTEMANIFEST 5. Generators Name and Mailing Address • " Generators Site Address in different than mailing address) ,So'n -"Uif) Co 5064 Was}eIs►viawn K*n Kimbrc Aendrews 1R�. B x, J0 San J�ui n Co t-1acaw ho" W2sk Ge, .M.Ao� CPQ C16,a0i a0il"44#53"7 550 S. 1d ford St. 6, Tra or 1 Company Name "' - U.S. EPA ID Number Gib45aUCXP E a c r IPOIAM iiia U 9 aad C) 7. nspo er Trampany Name U.S. EPA ID Number S�� xPR�� U.S. B. Designated Facility Name and Site Address,_ U. EPAIDNu ber Clean uarbors Lnulronmen{a l Ser-vtc..e, (Kimball Facile},I Facith es Phone IrSimball• "11 15 308 Q.65 gad©I I 1 V y & V 15 9a, HM 9b. U.S. DOT Desorption (including Proper hipping Name, Hazard Class, ID Number, and Packing Group (if any)) 10. Containers 11. Total Quantity 12. Unit WWoI. 13. Waste Codes No. Type 1 F"Icl bl l, -t u�d n.o•5 (Thlnner� 10'0. �( IN �IS� a W) 3JunIg43;�'1 l INA w C . M eBO l� 270 a,n1- �ela{FCt (Yea.}-eria-I,Ubto1 Th finer I t� ( ►tHw ) n�d(�3t�GII Gly" CF 1 N ^}- elated Mil e"ri 'aI ( Int Th,,�nerr (,cal X 0111-Qa5 1 IOT7 NNw 13 nw(p3)PG r I F-+6 r'YI aIA kit •SCd Cj II i-�Ql IC., IV• O. S. J -I. is n(3afj, PG +r C i,�tJtJ�,{%P1e61 1A'NI �15�r((G?Ifj eF 'N C tA �41LL� 17 ( Pyr )3 008 - •. C - 14. Special Handling Inslmctions and Additamal Information - �.)cl�a�dt�a1 x 15,3 15. GENERATOR'SIOFFEROR'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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and l am the Primary Exporter, I certify that the contents of this consignment confomr to the terms of the attached EPAAcknowledgment of Consent. I certfy that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if i am a small quantity generator) is true. Generator's/Offerors Pnnted7fyped Name Signature on ay Year --Dez, y l� o7 _G 4-10 ..1 Z 16. International Shipments ❑ Import to U.S. . / ❑ Export from U.S. Port of entry/exit s v Transporter nature for exports only): Date leavin U.S.: 17. Transporter Acknowledgment of Receptor Materials Tran er1 nnwdfIyped Name rgnature_ , aye/ Year morn Q Tr�.,^��p�jiteerr�2 Printed/Typed Name - 1 gni /Month Day Year 1J"'\ - CI 4.: a 1. Ci*'� - L 'r 18. Discrepancy I - - 4 18a: Discrepancy Indicalidn Space ❑ Quantity ❑Type 1:1 Residue ❑Partial Rejection ❑Full Rejection Mandest Reference Number. 18b. Alternate Facility(or Generator) U.S. EPA ID Number J 61 LL F li 's Phone rU .. Signature of Alternate Facility (or Generator) Month Day Year Z 19. Hazardous Waste Report Management Method CodesTi.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. / 2.=/z� 3. 1,�-%-e 4. 114(% 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the`manifest except as noted in Item 18a PrintedlTyped Name Signal Month Day Year orn rums orvu-u ,rtev. o-ual rrevmus eumons are oosoiece. DESIGNATED FACILITY TO GENERATOR rot