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Please print or type. <br /> Form Approved.OMB No,2050�M9 <br /> UNIFORM HAZARDOUS 1 Genera or lD Number 2.Page 1 of 3,Emergency Response Pttoaa 4,Manifest Tracking Number�q <br /> WASTE MANIFEST l I_.(1i3 "1�1 `i 7 1 (a t31I"7? 7 <br /> 10 FLE <br /> 5.Gorerata'sNam Ord Ma,4ngAd"15'lLf�fl.s'f� E 'r�L1�I� �,1:7d�i[(!aftttLtltfOriGennrakx'sS4oAdam(ddiEerentWnma3,rgaddress) <br /> ol <br /> 320Q S,SI E�arradv`rt. <br /> sAM'Rlpn'CA $� <br /> Genardtots Ptwo: z��- <br /> 6.Transporter 1 Company Name U.S.EPA Numtt <br /> Union('zt:he Lints co <br /> 7.Trnndpotter 2 Company Name U.S.EPA ID Number <br /> 3,Desxdnaied Fa0ty Name and SiloAddress U.S.EPA ID Number <br /> E Dt E r�vir rens rJi I Tt Gi3�' L 7 <br /> I f t# West llig)tua-�f 21 <br /> Frnb:;yi6 Ptxxse: '.. <br /> ga. 4b.U.S.DDT Descsipb n(ixit ling Proper Shippirq tdarm,Hazard Class,ID Number, 10.Containers 11.Total 12.UM <br /> HM ate ftr, tg Group(dar'A No. Type ouarruty Wtivd. 13.Waste Codes <br /> L d r fs r-y 7 <br /> Hp G yt <br /> (1 ( I ,.q .,sit:r ?"•iG3td'�I_t,.'.t 'I FiF'�t 7f. t..lta�,til�}ikt.�.'Y.F t I'��t1It�S'i� I i y 7— sT <br /> r2 2. <br /> t7 { <br /> 4. <br /> 14,Spoaa!tiandtng Instruc'xs ;banal mtamratitxh <br /> €Itdt;(tii'sAL � £t S4E FiEt Yt IJidr IaRCsI C'i PAILCA-R No <br /> p)eI3 I c�a. strT 1T x� t( p L� <br /> F: roBtCtA1 tit; <br /> Itr9` <br /> 15. GENERATOR'WOFFEROR'S CERTIFICATfON:t hereby declare the the contents of tors cynsgwrtl are tuily and acclratclydnsaited above by BW proper sKi";ng nine,and are dassiw,pa:aged. <br /> marked and la dCd,and aro 3g resporb n proper cmc l ar for tra!rspat aaordvg to appbcab�inter at�natand nor enol governmonta♦reg#atmrrs,Itexporl <br /> Exporter,I cmfy mat the cwk--tis of the arnsgnmont conform to the torts of the attached EPAAdimiedgment of Crsserk shown)and!am the PAtharY <br /> I certify that the WVsto!n rwrkaation s4 temenl danidx io 40 CFR 26227(a)(41 am a large quantity generator)or ib?(di am a shim i qua"gerxxata)is tnre. <br /> Crar4r.WslO fcrors Pmled/fypod Naim SagnaMe h J1 Day Year <br /> _j 16,lmomat on2l Strpn*ntso In per!o U S. Ff�11 <br /> L 1 Export frons u& Pat of entryrexll <br /> Transporter sentare(for exports o ttry Data Iea'mtg U.S <br /> iWrsup <br /> 17,7t srAduaov„4edgment arRera+pI of I&tefws <br /> TranspoMr 1 Pante 47y d Hama Signature hSorm Day Yoar <br /> R <br /> QTr nsponur 2 Pnn!edTypCd Nana Signature Month Day Yea-, <br /> a t&.D;mpancy � yy <br /> t8a.D SsraP Y Itd cnI»n Spat, MadlyMadlyL J Yypo ❑Rus#ua <br /> t— <br /> I�!°T <br /> Portal Rs&t;on ®FW Retectun <br /> Iab,A!;anateFad,ty(or C-enemio?) — ^��— festRekr Number <br /> U S.EPA ID Number <br /> U <br /> Fe", a PP'0'M <br /> W IftSignature olWte:naroF-;EktyrorenemtCr) <br /> htongh Day Year <br /> 4 <br /> 10,HWardohu Waste Ropan Management Mettaod Codes(Lar„codes for hazardous vssta treatment cGiposal,and roc)drg systems} <br /> W t. 2. 3, 4, <br /> 20.Lhusgnatod Fodity Offor or(7pera.or:Cott flcatzus at receipta(howdahs m onats co-wered try the m;u&slexrA%nv rded k%Mm t8a <br /> Pnn`rwTyped Name Sgrtakue s Month y Yea <br /> EPA Form 876022(Rev.12-17) Previous editions are obsoloto. DESIGNMED FACILITYTO G5NERATOR <br />