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Please print or type. Form designed for use on elite 12•pilch)typewrlter. ;:. Form Approved.OMB No.2050 4039
<br /> UNIFORM HAZARDOUS 1 Generator ID Number 2,page 1 of 1.3.Emergency Response Phone 9,fAanlfesE 7racktng`Numlier f (
<br /> WASTE MANIFEST €:, 1.€)U 0:194,30 7 i. (ifYtg4 4341 E =4 f �a "J"
<br /> eralots Name and Mairin Address
<br /> Generators Site Address If different Shan mailing address)
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<br /> GeneralorsPhone: 22:09 L001 CA 96240
<br /> 6.Transporter 1 Company Name U.S.EPAID Number
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number i
<br /> 9F-G0'VF-QY$Y -FQ1 INC. A f U rJ
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<br /> Fadliysftne:
<br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11J.1.1 12.Unit 13.Waste Codes
<br /> HM and Packing Group(ll any)) No. Type quantity WIJVoI.
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<br /> 14:Special Handling Instructions and Additional Informallon r..F F :J ':1 '-f,
<br /> ("HE�TAFEC 149,')07 4`2.4-3300 WOE-13 �APOINAL.'C;M9 08 �PROFIL'E V OB :16 6?�I�f�8#"V113�4 a
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<br /> 15. GENERATOR'510FFEROR'SCERTIFICATION: Iherebydeclarethatthecontentsofthiscoosignmentarefullyandaccuratelydescribedabovebythepropershlppingname,andareclassmod,packaged,
<br /> marked and laboledfplacarded,and are In all respects in proper condition(of transport according to applidable inlematioaaland national govemmenial regulalfons.If export shipment and I am 8ce Primary
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<br /> Exporter,I cedily that the contents of this consignment conform to are terms of the attached EPAAcknowledgmentol- onsent. €
<br /> I certify that the waste minimlrallon statement Identified in 40 CFR 262.27(a)(if I am a targe quantity generator)or{b} Ill am a small quantity generator)is true. Month Day Year
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<br /> ,J 16.Inlemalional Shipments ❑Impart to U.S. ExPo❑ rt from U.S, Port of anlrylaxfl:
<br /> Transporter signature(for exports only): Date leaving U.S.:
<br /> 17.Transporter Acknowledgment oiReceipt of Materials
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<br /> ler 1 Pdnledlfypgd Nam r' ! Signature la, Month Day Year
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<br /> Transpo ei 2 Pdnledlfypetl N a -" r.' + Signal re �•_ -'., Month Day Year
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<br /> 18,oucrepancy �I
<br /> 18a.Discrepancy indication Space LlQueenly ❑Typo ❑Residue ElParUal Rejection ll Fotl Rejection
<br /> Manifest Reference Number:
<br /> U.S,EPA ID Number a
<br /> 18b.Alt&rrrate Fadllly(or Generator)
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<br /> ua FaclliVs Phone: Month Day Year j
<br /> Cl 18c SI natureofAllematoFacili(orGenerator)
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<br /> 19.Hazardous Waste Report Management Method Codes(i:e.,codes for hazardouswasle treatment,disposal,afid recycling systems)
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<br /> 20.Dostg atepi Facflily Owner or Operator:Certigoation of recelptof hazardous materials covered by the manifest except a.r1i in Item 180 _ Moi Day Year,_
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<br /> EPA Farm 8760.22(Rev.3-05) Previous edltlons are obsolete, A i ED PAC 1LI T Y E0 GENER''i0R
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