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Please print or type. (Form designed for use on elite (12-uih .writer.) Fnrm 4nnrnvod 0000 xln 9051 rVVIO ED FACILITY IV GENERATOR UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number © 2. Page 1 of 3. Emergency Response Phone r7 J 4. Manifest (T'r�acking Numbers _ Q Q Q ,� 5 $ C'r 3 1, FLE 5.G&neretors Name dl Mailing Addres Generator's teAddress i(different than mailing address) Jqn JC (frr) o Pcit�J I�rrnk,rct AndrPu ail .Y-oqulo Co• IktA+5 tiolb hR rcd�u tiAZ�-Float u305fr. Focllit� '�9Sp ,�ibjy•�lQ� 4'-Tt�N CA 1- 61Q.Of `.�. I�.%� 1I}G �. ?" Genelato4's'd (� 6. Transporter 1 Compan Name i Y U.S. EPA ID Number i k r, r r p 7. Transporter 2 Company Name _ h" U.S. EPA ID Number B. Desinated Faall Name and Site Address ` U.S. EPA ID Number cIe�an t�-iarbors civ 309 ArnaRtGa.N CIrGIle Fau�yi1ys�AX cio . (a p- '11 i 30 1910 61n5 11-13 t qb 9a, HM 9b. US, DOT Descriptor; (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group If any)) 10. Containers 11.Total 12. Unit 13. Waste Codes No. Type Quantity Wt.NoI. 1 Flammable. P-I�Ut s, NOS,a L%AH431 7r, T �/ Ia IGf�liUr , �F C k() LUtTlI irI 1LI�CeS�, (Cr ' I m_i3� [Jl"' 5 I� X37 C1 k w " 2JF'`(.Umm�ble `Jc'Itd�,UP r�rG,tvl.U.S.r�.ixUnJl �� � � X ii'illlESrVCS, I+� I�urn ll/zICS� (Pti7�' 133) LF O i l l a Al 3.�r� NE�ilc117e.a Lf�utd, Ic+mmabfe.;ic:o(rG, 1.1 d9� f, ✓Cid CF1 j LhiCNY�Gr/� L )� NY) ry�� to I. }[ ,tN IL- n, euro DISC ,� T (0 :131 (P r= ` r� , X7 1 �, JolS /Q AT grlc.. A+hAta ! rCv�a„�S N.CkS B,uA 7r9, pC,� Leta Ockb-Fmk )Jerr� 15-0 CVt~ G(tjtiW3a) bf: C}U 00M/� 14. Special Handling Instructions and Additional Information 1 chago(pjq $ Y 55bF a.)CH�1400 7°1 x mi&-:Fr?�x55O(r) +�+•) C'.4i<�i�-i0 to 3.�„ ..3... x 55 bF .��`'"" ✓ r- ��r.� A�irC„� 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 I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quan0y generator) or (b) (if I am a small quantity generator) is true. enerator's/ eror's PnntecV I yped Name signature on ay Year F L. C) 16. International Shipments ❑.- Import to U.S. LJ Export from U.S. Pod olentry/exit: - Trans oder signature for exports onl: Date leaving U.S.: w 17. Tram poderAcknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature on ay Year y Q po / Transr 2 PdntedRy1 ped Name `-' ignawre - 11-- �- ant Day Year 110 Discrepancy t18. fits. Discrepancy Indication Space ❑ puantl ty F-1 Type El Residue ❑ Partial RcldCtion El Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U ra+• Facility's Phone: Q iBc. Signature ofAltemate Facility(or Generi Month Day Year 2 rn 19. H ardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) w D 1. 2. I 3. - 4. 20. Designated Facility Owner or Operator: Cemficahon of receipt of hazardous materials covered by the manifest exceplites noted in ItsmAffa Printetlrfyped Name '\ Signature( Y � 1. � ,,... i 1 b7 Month Day Year 1 ' "" 1!•.. iv �'� � �,'�41�. •� ?� � (J �.. EPA Form 8700-22 (Rev. 3-051 Previous edifinns are nbsnlele. "- newnuer ED FACILITY IV GENERATOR