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V <br /> /please <br /> orm desi ned for use on elite(12•pth) pewrbr. Form Approved,OMB No:;2050.0039 <br /> 1.Generator ID Number 2.Papa 1 of 3.Emergency Response'Phone an wn'FT:3T }3717 i 4 t&828.8772 FLEe and Mail ng rasa GsnerewA Bite Address(a dmnt than mailing dress <br /> LWtUFFjAL AJC MCYCUNQ Afn Wifflam fid"uS <br /> 3200 S i_!Dotado St. <br /> loOK1,11,CA <br /> SM <br /> Gerraratots Phone: <br /> ranaporter ompany ma _ U. ;EPAID Number <br /> Won Padfic Lims CO d <br /> T. raneporten2 pony Name U.S.EPA ID Number <br /> 8,Designated acilq Nama and Ka drags U.S.EPA ID Number <br /> 11Iti VVeg Hkftomv 123 <br /> Facilit es Ph A -aa51 Fara Omton,UT M620 iia <br /> ga. 9b,U.S.DOT Description(including Proper Shippipg Name;Hazard Claws;ID Number 10.Container 11,7da1 12.UnK 13.Vyeate Codes <br /> HM and Padang Group Of any)) No:. Type Quantity WtAbl.:; <br /> 1 <br /> N,(7 d-�kr1 .,. WAS-M,SOW{ Pte" ) �i Fid <br /> 2 - <br /> i� _ w <br /> 3 <br /> 14. polo]HandBng inwtrudlonw and AdM#Ionat Infotmatbn rr fq <br /> NON-RCRA <br /> � S'9t3 <br /> 15, GE-NERATOR'SIOFFERORIS'CERTIFICATION:'Iharabydeclare thatthecontarhofthlsmnsigimenLuefu#ypd4wA..*clawizibedetrovebytliaproW811lppingrratne;entler4 PnckeGed <br /> marked and labeled0kardscl,,andarain eK rewpacte in proper oai,ititldn.fotharaporlt axoNing ro app(ksbie aril nallotie!_povarimreMnt ragulatidns:!f expori eh ptnont and I am tha Primary . <br /> EWtar,Icerofyghatthe cmtentsofthis oona1pnmentconfdrrntottw"Of thdattathedEPAAdmowladgmaiifofGansant <br /> I cadlfy that the wastamktkntzaflon statement Idendfled ln48 CFR 282.27(e)(df lame large quantfly gef(#alar):or Ili(M f am a aRxik.qusntNy ganaeta)to he, « <br /> ffrMw@QftW6 maMn <br /> o <br /> .J 18:international I>}pntort#e port <br /> ❑imto U.S. ❑Expat from U.S, Port of.wrtrytatdt: <br /> Tra lure for on Date E®a U.S.: <br /> _tl:trans{nrtofAcknrtrAadgmsnfofRemoofMatetials <br /> renspotwxy ear <br /> WINama�r <br /> 1_77 12 A <br /> cy? 001 <br /> j Transporter 2 Printacirryped Nm6na y oar <br /> 18.Disaepancy <br /> 18a.Discrepancy Indira Space <br /> ❑Quantity ❑Type El Residue Padtai Rejection ❑Nllklocton, <br /> :Mard(eai R Number. ,4� <br /> 18b.AKsmate Fadiq(or Genamtor) U.S.EPA ID Number <br /> u <br /> u Fadk s Phone: <br /> 18c.Signature ofAKamsta Fa Ky(or snertu� Year <br /> 19,Hazardous Waste Rapart Managemenf Method Codas(i.e.,codas for treatment disposal,andracY9 eye ) <br /> O 1. t< 2. 3. 4 <br /> !1 <br /> 20.Designated Fad4 Owner or Operator:Cmtkaiion of receipt of hazardous rmtedals"covered by the mardfast except as noted in item 18a <br /> Printed1fryped Name nature ay PON <br /> 10 , <br /> EPA Form 8700.22(Rev.3.06) Previous editions are obsolete. ESIGNATECI FACILITY 70,Gf NERATOF <br />