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S <br /> RECEIVED <br /> Please print or tM WLW19a Form Approved,OM9 No.2050-0039 <br /> UNIFORM MANIFESTS 1 GrerAera�QlD�Numl>er� .�Pag 10l 3�Emergency Response Phone a'Mtar�[eetTrr�kiny Nyr,r�c 3 2 JJ K <br /> WASTE MANIFEST 1.J1 0 U 19 R/}!� U <br /> 5.Gen a an nd Mailing Ad Lao� � of us N ins Site Add d lift ) <br /> X aft of US XNSA <br /> PAL B=SM/L-7W Uvemwn CA 9+4551 hind Naft t Road.Trm CA 9537!<i <br /> Generator's Phone: -LW5 aTFIt ShWoke <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clmn Harbors Environnulntal SerwWas Inc. IVWDD3987�50 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated Facility Name and She Address U.S.EPA 10 Number <br /> Omn SQtrdrrr3 of sm Jaw,LLC=1 Besrymm Ro2d sea Jane CA 9S 33 CAD0594MIO <br /> Farah s Phone: 451-M <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11 Total 12 Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity WUVal <br /> X1 UN1993,Waste,RarrtnWWO ids.n. ..3,R(Lcb pet)EERG 1 DF i7s P 01 D035 <br /> 331 <br /> X2. UN1993,Waste,V Wd!6 rLo-%3,0(Lab pad)[ERG JIM D035 <br /> UM M08=4 <br /> 1 <br /> 3 UN1M Waste,GEM&I .3,R IRG 1A DOPOQS4.1 i DMA 4a -w1 <br /> a RESIDUE:lank contisinod UN1494 Sod#arn nkrase,5.2,in[ERG I DF 25 <br /> 1401 DDPUW&1 <br /> 14.Special Handling instructions and Additional Infonmatlon <br /> H Y M Phone 9 Corfu r>; m UAL Emerfmtry�.Load 4 SJ20-19,Ship Doc fro-Sr•2'f 7 <br /> ARlbrr cs E�� on br+++s>m Soo attashod far cand nor manbom <br /> S y BCD -QtO " W&Y, 01 ode 9 5 5 . <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are hilly and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labele&placarded,and are lm all respeds In proper condition for transport according to applicable kntematlonaland national governmental regulations.tf export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conIbr m to Ile terms of the attached EPAAdTaMedgment of ConsenL <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(il I am a large quantity generator)or(b)(if I am a small quantity generator)Is true, <br /> Generator s<Dreror s PrinledlTyped Name Signature Month Day Year <br /> Scot A.Graham ork bMvdf of US P1WA Z ao <br /> j 16.international Shipments <br /> ❑Import to U.S. ❑Export from U S. Port of emfrylexil: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17 TransporferAdpowledgment of Receiptot Materials <br /> Transporier1 P'tedlf ame _ Signatu onth Day Year <br /> spoiler 2 Prin-Wayped Name nature -` r Month Day Year <br /> 18.Discrepancy O <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Re*91 ::1 Ful1 Re)eclian <br /> Mantes[Reference Number. <br /> 18b.Alternate Fadlkty;or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> U- Facility s Phone: <br /> W 18c.Signature of Aktemate Facility(or Generator) Month Dey Year <br /> a <br /> z <br /> y19 Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal and recycling systems) <br /> LU <br /> 2. h// <br /> / 3. /. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazpfts materials covered by the manifest except as nded in I 1 <br /> PriniedfTyped Name Signatu Man D Year <br /> EFrA Farm 8700-22(Rev.12-17) Previous editions are o sale'!. ESIGNATED L=ACILITYTO GENERATOR <br />