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LIVLU ." or type. Form Approved.OMB No.205DM39 UNIFORM HAZARDOUS I.Generator ID Number 2.Page 1 of 3 Emergency Response Pharse �.Manifest Trackl Number WASTE MANIFEST W89t�0U2 1 92S-423-4205419 4 45579 JJ K 5.Generator's Name and Malsrtq Address Generators Site Address(if d4lerant than mailing address) LBWrCttO�LhlQlirlOy B I I�Ofi4{Lob 57t!'3!]O Of1 f of t E lL'�} 7V5A U lME=re MffftrW LL'h ME 3D CA b~Of da 1111 WBA P.0-Dx IM/cuss fie a M51 wnd HaMalldr R02d TMCY CA 93376 Generatoes Phone: 925-4V-1925 ATTN: 6.Transporter 1 Company Name U.S.EPA 0 Number Clwn Harbors EnvironMental S0iv1= Im MA=93MM 7.Transporter 2 Company Name U.S.EPA ID Number i I4ot" ! 6a D, -;;-OL 827 8.Designated Facility Name and Site Address U.S.EPA Id Number Cilmq hlairbw+ W,,z LLC 11=NWth AptM R -A AMWM UT 84M LRMISS2177 Facility's Phone; 9a, 9b.U.S.DOT Description(ncluding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM I and Packing Group(iany)] 13.Waste Codes No Type Quantity Wt.Nd, 1•IIN3379,Waft rJesmshized eWkdve,k0d,rLO.di.(ItMX,RM, DAA 471 P DOM I FORS 3,i WT-SP ISM){ERG M DOF'BDS*X-I 343 LU 2. ►uni xS,w ,P01YdidWi,.-t, t , a,9,111{oUc Of DM w sterVke Deat05ill7MM[ERE 1711 DoP0075-2 261 3. RIL UN2315„bmte,POWhilobated ttolr ly s,Ugaid,9,19(out of 30rrk6 We 03/IVM19)(ERG 1721 DOP0075-1 ?.Z1 261 a M UUM3Z Was#,PdVd*WI4KVd WM4%Ea1id,9,IN{OW of R Sarvlca Data 0312*2118j{ERG 1711 DOM31-1 751 261 14.Special Handling Instructions and Additional Information E"*WM Re4l0wll M5423-4�-ConW na 7 e rwi_EMME f►fir MVattk L02d V At,P r UW6, Qac Mm S-251172, Idem rdeM MMdw XE 0 32 on it1 . QOMM9=c lt-SS,Q00MOK 00GE3135$0 15. GENERATOR'SIOFFER.OR'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,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemabonaland national governmental regulations.If export shipment and I am the Primary Exporter,I certify Thal the contents of this consignment conform to the terms of the attached EPAAclmowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(41 am a small quantity gengrator)is true. GeneralorslOtferors Printed/Typed Name Signatures Month Day Year SCM a C-48teM on WWI of the U.S.NNSA 16.International Shipments F ❑Import to U.S. ❑Export from U S. Port of entry-exit: M Transporter signature(for exports only): Date leaving U.S.: � 17 TranspoderAeokowledgment of Receipt of Materials Transport r t Pnnte&T),ped N70 t Signature ) Mach D/ay Year a Z 19 Transporter I PdriMff NameMISS KVY r— (1 A/� J/ GL Days, Year 18.Discrepancy 18a,Discrepancy Indication Space El Quantity 1:1 Type ❑Residue El Partial Re)eclion ❑Full Rejection Manifest Reference Number. 18b,Alternate Facility(or Generator) US EPA ID Number U ra+. Facilitys Phone: W 180.Signature of Aftemate Facility(or Generatori Month Day Year' a z 19.Hazardous Waste Report Management Method Codes(i e..codes for hazardous waste treatment,disposal,and recycling systems) LL! 1 ?N D i k 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manliest except as nded in Item 1 Ba PrmtedlTyped Name 4 t Signature Month Day Year Ei'AForm 00022(Rev.12.1 Previous editions are obsolete. DESIGNATED FACILMO GENERATOR