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Form Approved.OMB No.205G-.0039 <br /> Please print or tyke.(Form designed�use �(lch)typewriter.)t. ge t at 3.Emergency Response Phone 4.Manifest TrackIn Number <br /> UNIFORMHAZARDOUS fi82387T 2421 LWASTE MANIFEST7 <br /> 5:Generator's Name and Mailing Address Genorator s Site Address(t dfiorenl than maifng address) <br /> # td Rt p1 SVC REQ:'fCLING .Aids kNWI;61 f-1k1t1tiOrg <br /> Dorado St, <br /> atixRKtf3[I:CA alfa <br /> 9A <br /> Generator's Phone: U.S,EPA ID Number <br /> ransperter i Company Name 7 <br /> fnitlrr Pawfirr Lines CK) <br /> 9 10 <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA lD Number <br /> 8.Das goofed Faliiy Name and SileAddress <br /> (<=�;§ �•�t14trCtfltYi�ils'r§f �`-09�Sis:2210'f <br /> Fad Phone; <br /> 10.Containers 71.Total 12.Unit 13.Waste Codas <br /> ga- 9b.U.S.DOT Desc fpuon(including Pager Shipping Name,Hazard Class,10 Number, No, Type Quantity Wt NOi. <br /> HM and Pacldng Group(d any)) f <br /> ® {s?3HAMRDOUS a l a i 1 §:%t tai C»iT k i, '. . <br /> 2. _ <br /> 3. <br /> a. <br /> 14.Special Handling instructions and Additional Information <br /> !lil'i §? f4^f Fi i:'Yet-IN(3 Nf"!t_l,}ECT [ RASLOkP$SCS. <br /> E-GO�PK IW41 sG€sok <br /> 15. OENERATOR'S10FFEROR'S HRTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified;packaged, <br /> marked and labele&pyacarded,and are in ail respects in proper cb�tion for bansportaocording to applicable international and national govemmental regulations.if export shipment and tam the pr maty <br /> Expariar,!cert fY that the cohtents of this consignment conform to the terms of the attached EPAAc owtedgment of Consent, <br /> I certify that the waste minimization statement identified in 40 CFR 282:27(a)(d t am a large quantity generator)or I am a small quantity generator)fsbus-zqg <br /> ay asr <br /> Generator'si erors d Name na re t <br /> $'B h 6 Il f <br /> r 18,tntenall nal Shipments Import to U.S. ❑Expert from U.S. Port of enbylexit: <br /> N- Date leaving U.S.: <br /> Tran cher s' afore fore "its onl °: <br /> W 17 TranspatlarAdmvrrfedgrrmm of Raceipt of Materials Yay' Gar <br /> IR Transpartaf i rin Nama, <br /> -o <br /> VA:V Aon ay ear <br /> Trensparter2 pr ntad Typed Name ignaWre <br /> i 18.Discrepancy � <br /> 18a.Discrepancy indicallon Space 4rentity t llypa ❑Residue I�Partial Rejaction El Full Re}ection <br /> Maeifest Reference Number, <br /> U,S.EPA ID Number <br /> 18b:Ntemate Facility(w Generator) <br /> Facili s Phone: - -- Month Day Year <br /> 18c.Signature of Rdlemate Fao l'dy(ar Gemarator} <br /> Q _ <br /> i9.Hazardous Waste Report Manacemart MetMh d Codes(f.e.,oodes for hazardous waste,beaimeni,disposal,and recycling systems) <br /> til 1 3 4. <br /> 20.Designated Fealty Owner or Operator:Cer6fice6on of receipt of Hazardous materials covered by the manifest axxpi as noted in Ilam 18a y Year <br /> Prin.adtTyped Nama / �- _mature ! <br /> PA Form&700.22(Rev,3-05) Previous edit ons are obsolete. IGNATED FACILITY TO GENERATOR <br />�i <br />