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/ase iinE1or type.(Form designed for use on elite(12=pitch)typewriter)• Form Approved,OMB No:2050•th <br /> UNIFORM HAZARDOUS 1•Generator ID'N mbar 2.Page 1 of 3 Emergenoy Response Phone A*Manifest Tracking Number <br /> WASTE M/tJ1FE5T: . ) t .rak :7 ��pggqWO P d2 <br /> `0V J A C.. <br /> 5•Generator's Na'e and Mailing Address Generators Site Address(d d(tferent than maptng address) <br /> 3027'CLARK DR,- ' <br /> Sf t i t� CA 9621 b' <br /> Generators Phone: <br /> 6:Transportar 1 CompanyName. U.S.EPA ID Number <br /> WORLD 0L Et4ViROP3MEATALSIMACEa Qr A 0 0 2 Eb 2 7 •i'0.a^ <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8.Designated Facility Name and Sfta Address U.S.EPA ID Number <br /> %iMIRY�NARIOk'*ti+11E'NTAk.SERVICE .CERffs <br /> A-92&MOOGM R11 <br /> Facill s phone rih, E_ :l "rsi r [. �0 0 8 9 3,6 <br /> 9a: 9b,U.S.DOT besci ption(Including Proper'Shipping Name;Hazard Class,ID Number, 10.containers 11,Total 12:Unit <br /> HM and Paft§Group(if any)) No 13.Waste Codes <br /> Type Quantity vVUval, <br /> t:, t <br /> o q-RGRA}4MR0(068WASE> L?Qt}6f)/USW bi f NXED OIL) <br /> 875z 2:> <br /> c� <br /> Asb iry. fin i�n iatdt 1 Sarnia�-Caras <br /> Jo <br /> 14.Specie!Handling instructions andAddlttoMaltnformaUcn• <br /> i is fi 'Af y T :fit aREQ :k4W24-9$00Ah*M`#'wf3bt(ML. 'dAPPs: f'4 t k' ,MRSONA. L PCa'i 0136% r Lt3 4 Q1 i�f <br /> ntatwt;' 3� , # Z � Lf " dt3. k �:�T"fa(df'.3� .. . <br /> 15. GEN?RAi OR`SfOFFEROR' �Ei€i(FfCA CON Yhereby�declare that the contents of this consignment are.fully and accurately described above by the.proper shipping name„and are classified,packaged, <br /> marked apu labaledlplacsrtled anaare fn attrespe lsin prop�r co tion for trap§pdit according.to applicable intematipnatand national governmental regulations:If export'shipment and I am tha Primary <br /> Exporter icertdytitaflbe edntehis bfis f dnslgnma�it'coiifoim to the terms:6f the attar hed EPAAcknowledgment of Consent, <br /> Icerpfythalthewaste nimrnzLattonSt@fenie�}tCdentdiedin4U:CFR262:27(a)(ifi.amalarge'quantifygenerator}er.@)(iffat asmaf(yuanGtygenetator)Cs€rue. <br /> Generato�slOfferors Prmtedl3ypad tVarne Signature i" Month Day Year <br /> J `16.international Shipments V <br /> D Import to 1J;S. Export from U.S. Pert of entry/iii: <br /> Tragspottetslgnatpce(farezpoitsonly):.;.,, Date leaving U.S.: <br /> 17..Trenspoit rAckh&ilWd 6i6hV6fReWotofMaterials. <br /> Transporter 1 Printedfiyped NamB Signature r'r Month Day Year <br /> 0 <br /> .iG...;. <br /> ansportar7PrintedlTyped Name igrfiatdte=i f rAonth Day. Year <br /> 18.Discrepancy . <br /> 18a,Disc#ancylndicati6nSpace1� <br /> Q <br /> Quantity, Type . ❑Residue• El Partial Rejection Q Fuil Rejection <br /> Manifest Reference Number-, <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> Fadlity's phone:, : <br /> LU <br /> 98c.Signature ofA(temate Faci i9y(or.Genarator} Month Day Year <br /> w18.Hazard'us Waste Report ManagemantMethod Codes 0,e.,codes for ftkardouswaste fieatment;(Ysposal;and recyding systems)' 3 <br /> 4.20..Designated Facility Owner or Operator.CertiticaUbn of reaelpt df Hazardous materials ooverad by the manifest except as noted in Item 1% <br /> Printedlfyped Name Signna••ture Aa <br /> Month' ay Year <br /> . .' . '. f:F 'TtI111A #4.::,..._ � St,r, S� .e 411r®�d�r'.,r ... . Rr: cxs <br /> EP4 Forti1870fl 22(Rev.M5) Previous edi ons ale obsolete, DEMGMATED FACILITY TO GEN09 <br /> Ir: <br />[I <br /> I <br />