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* <br /> 0061922S551< 111 <br /> p1 '' f q mdetined for use on elite(12 p tch)typew kr,) Form A oved OMB N k Og <br /> Generm or 10 Number 2.Pwf 1 of d en raekl Number <br /> WAST �9 0001 22 5 5 SK <br /> 8G ieraioraNeme'a1MMarNttgAdtltess Generators Site Address In different than mailing address) <br /> CA 95,13"-1641 <br /> . U.S.EPA ID Number <br /> n } v U.S.EPA ID Number <br /> 9�fi INC. IRf#IFQs3`a322c? <br /> OF WILMINGTON UZ ., U.S.EPA ID Number <br /> *- CAD044429831i <br /> r�gep.Na$arfGase ID Number, 10,Confamers 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity WWd. <br /> :. tb P .223 <br /> n <br /> T <br /> l <br /> >r <br /> x, <br /> 4 <br /> r z t <br /> 1 bf tFiiadgh5�gnment are fuly awl accumteydescnbed above by the proper shipping name,and are classified,packs <br /> aTnd forfr spotlaccor`rrrig mepplcaple olemabonaland nabooal govermmeMal regiNafions.dexpon shpmem and I am the Primary <br /> " #td" ''dmeerradned EPAAcknovaedgment of Consent <br /> 27*1if I ams large quanbtygenerator)or(b)(di am a email quantity generator)Is has. <br /> signpture Month Ro Da Veer " <br /> i' <br /> ❑Export from U.S. Pon ofentry/exit <br /> .. r,-.•,r Date leaving U.S.: <br /> nature Month bay ear.. <br /> nature Month Day fear.. <br /> T y ❑Type ❑Residue ❑Partial Rjecton ❑Full Rejecti <br /> µ L <br /> � .Manifest Reference Number: <br /> ieb h nfmf€ [y of '' U.S.EPA ID Number <br /> ta. FaClldy'S Pixma' <br /> �i iBc Signature dfNtefiafe R@ mth . .Day Year <br /> Q <br /> 19.Hszsrdous4tlaste Repot Manageiopm Methed ndeb;i.e,�codes Por hazardous waste treatment disposal,and recycling systems) <br /> 20.Designated Fadlity Owner or Operetot,Cedfeafion ofreceipt of hazardous materials covered by the mandest except as mfed in Item 18a <br /> pad Name Signature Month Day Year <br /> EpAFerm6 00 2(Rev. 0 }� reviodseditionsateotisolate. DESIGNATED FACILITYTO DESTINATION STA E(IF REQUI ED) <br /> � 1 1 . 3# 7 <br />