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r Please print or type.(Form designed for use on elite 12- Itch)typewriter.) Form Approved OMB No.205( <br /> wy" UNIFORM HAZARDOUS Generator ID Numbor Pn a 1 of T EpmoMoncy Rosponso Phono 4.Mnnlfest Tracking Number <br /> WASTE MANIFEST CA�oQ303��6b ( )y2y- 9300 018241995 JJk <br /> 5.Generator's Name and Mailing Addross Generator's Site Addross(If different than mailing nddrose) <br /> Xil <br /> S-NZ HL-MY RA <br /> 85151 N mkcA2- 012 D)Z <br /> to `�(Lpr(r1 CA aSS74 <br /> o Generators Phone:(Zoq $33 —'7167 I <br /> T 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 2DOrAC- -TM- NI;Ru%cFS I CN�o2g� x-7036 <br /> U 7.Transporter 2 Company Name U.S.EP ID Number <br /> J <br /> m <br /> 8.Designated Facility Name and Site Ad^d'res,Ls <br /> B� 5F,5fIELD —MWS5K' 1NL U.S.EPA ID Number <br /> -- �20 $RUNDA,&f-_ �i,ANE <br /> R sFtr.Lp CA a330'7 CAL ODD 20 2V > <br /> Facility's Phone: (661 1-77 03o 9, <br /> ga. gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> 55 No. Type Quantity WI Not <br /> -FT NbN-RC RA� 4k?AMOL)5 LAt,-(F uQ')1D QIv14 -t��2� T'( �'0D G 2 4'3 <br /> m Qr <br /> m z 2. <br /> c w <br /> E <br /> 3. <br /> w o <br /> 4. <br /> N <br /> m <br /> 0 <br /> 0 <br /> 0 <br /> r <br /> i4.Special Handling Instructions and Additional Information <br /> 3 <br /> sN�RLFfi1Cy ,coNTAf,'C; C4,(r- l-tVMC, 14bb-414- ct3O6- WbES "Tfr�R,MfNAI. CoNy -ToN <br /> Z <br /> S. <br /> _ 15. GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> z <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> co Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> � I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)lift am a s all quantity generator)is true. <br /> a <br /> o Generato s/Offerors Pnntedffyped Name Signature _ Month Day Year <br /> 4 <br /> o.International Shipments <br /> w f— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> �L Transporter 1 )ted/Typed Name Signature Month Day Year <br /> N �,�,, � � 111 25 I°I <br /> 4 Iranspo e 2 Pnntedffyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity, ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> FacilitysPhone: <br /> w 18c.Signature of Altemate Facility(or Generator) <br /> Q Month Day Year <br /> Z <br /> w19.Hazardous Wasle Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1. 2. 3. <br /> a. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded�In Item 18a <br /> Printed/Typed Name Slgnaluro <br />