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o- <br /> Please print or type Form Approved.OMB No.2050-D039 <br /> UNIFORM HAZARDOUS 1 Gecerator i D Number 2 Page 1 of 3.Emergency Response Puma 4.Manifest Tract] Number <br /> WASTE MANIFEST 20=5 19 4 5 5 6 7 JJ K <br /> 5 n s`I� res t Generator's Site Address Id different than mati'ing address) <br /> y.��. 1a3MA�11 k101rC�51 1'R I a d U3 F6ISIt <br /> 7=ECS AM-Ir7M�#1a1M1LM'f CA 29M IAM UM hm Jw"ft"CA 94q <br /> Generator's Phone '29S Anit G <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> 7 Transporter 2 Company Nam* U.S.EPA ID Number <br /> S Designated Fad ity Name and Site Address U S.EPA tD Number <br /> LOW0110 tkK ; MDR:4 COR+,M4 SW CGf rd i h' w IWA 7rMT CA 953$ CAUCYY1Q(M <br /> FadGttls Phone <br /> ga. 9b U S.DOT Description Lriciuding Proper Sfupping Name,Hazard Class.ID Number, 19 Conlairters 11 Total 12.Unit <br /> HM and Packing Group id any!) No Type Quantity WLFM. 13.Waste Codes <br /> (OM-SP 1 [EM 124 EVAF 352 <br /> w <br /> x 2 <br /> W <br /> 3 <br /> 4 <br /> 14—Soffcial Handing Instrudwsand ditfamali f <br /> �F ane$i�sr Cwt LM EV=gW V JgK)d jD 2Daj,(o 7a r65 7'`vts <br /> Q0�f iD. -�w -W-�+. 'i '�CS� <br /> __a rdWd 407��M G r:f15/�n rfi�I7'�: <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified,parhaged, <br /> marked and Iabe[edlplacarded and are in an respects In propercondi[ion for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Exporter I certify that the contents of this consignment conform to the terms of the attached EPAArkmowledgment of Consent- <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(aj(d I am a targe quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoeslOfferoes PrintedlTyped Name Signature Month Day Year <br /> . <br /> GMhM on bahi!ff of the U.S.MWA <br /> I/ // <br /> � 16.International Shipments <br /> �. ❑Import to U S ❑Export from U S Part of entrylexit <br /> ? Transporters gnature(for exports only Date leaving U.S. <br /> W 17 Transporter AdTiowledgment of Receipt of Material <br /> IE Transporter I aWedJyped Name!�J <br /> !'7 f! Signature / / Month Day Year <br /> efe <br /> Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> F <br /> 16 Discrepancy <br /> 16a.Discrepancy Indicaton Space l Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b Afsemate Facility i or Generator, U.S EPA ID Number <br /> C.1 <br /> W <br /> Facility's Phone <br /> WC318c.Signature of Alternate Facility;or Generatori <br /> Month Day Year <br /> U) 19.Hazardous Waste Report Management Method Codes 11 a.codes for hazardous waste treatment disposal,and recycling systems) <br /> LU p 1 <br /> 20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrinteCyped Name <br /> Signature Month Day Year <br /> EPA Form 8700-221Rev 12.17) Previous editions are obsolete. I TRANSPORTER COPY <br />