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Pease print or type. Form Approved.OMB No.2050-0039 f 1.Generator ID Number 2.Pae 1 of 3.Emergency Response Phone 4.Man ra e N UNIFORM HAZARDOUS ' g n`erg n�ih WASTE MANIFEST CAL 000 288 54 0 1 610-541-2128 t F L E 5 Generator's Name and Malmg Address Generator's Site Address(if different than mailing address; rnlrlsn'ra!a1 11rcJ,r: 3ere'atcrsPhone: •)�� ' i�� 6 Trans:orter 1 Company Name U.S.EPA ID Number Biq ky F:nvirowntio?a! SrAi CAL.0003.40n 10 7.Tran.sponrr 2 Company Name U.S.EPA ID Number t:O biduslrl7i Setvvice Wf14 435 64'' 742 B.Designated Fau dy Name and Site Address U-S.EPA ID Number (I-,ErnIf-;r fighaayl� . ,l-r, . -G19il „r ,ttr NVU nn-' �ncne 775 551-e 203 NVY33,0010000 y; p US DOT Descuption jinclud:ng Prcper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12.Unit r„ =Pa_,rg C-0.,p of any)) No. Type Quantity Wt!Vol 13 Waste Codes o �v ! 35� ' _ - - Han--tCRAHazardous Vlaste, Solid (Ur hrisl f� Z 2 LU 3, i N)$pe40aApppg.lnslru.jons and Additipo Lllnfprrn�kpn 41 rOfW h' 07017;;300-25 I f;i F:'fAERGCNICY CONTACT .IEFF"RHMF`� 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the prcper shipping name,arc are class fed,packaged. marked and labeled+placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regula;:cns.If export shipment and I am Lhe?rimary E,porer,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I ceruly that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)iii!am a small quantity generator)is true. G 4rvDfferors Pritit dtlTybed Nadia-, Signature Month Day Year J Export ort from U.S. Port of entry/exit: /exit: � ❑Import to U.S. ❑ p fY _— ? Transporter signature('or exports only): Date leaving U,S.: of 17 Transporter AcknoiNedgment of Receipt of Materials I.- Transport t 1 rmted dt '�� ,�`"'� Signature / Month Day Yeaar Cl)0 IL Transp, Pnnte^ Signature r Mcl!n Day Year tr 18 Discrepancy 18a C'.screpancy Indicaticn Space ❑ Quantity 0 Type Residue ❑Partial Re;ecton E Fra Re;ea-- Manifest Reference,Number, 12 18C Ahemale Faal ty Icr Grneratort U.S EPA ID Number J U ' Fa.',dy's Phone. W 18, Signature of Alternate Facility(or Generator) Month Day Year Q Z y19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,dispcsal,and recycing systems) 0 1 2. 3 4. i 20 Des,-a'ed Facility Owner cr Operator:Certification o'receipt el hazarcous materials covered by the manifest except as noted in Item 18a Pnntea7)pOName Signature Month Day ea EPA Fcrm 877G22(Rev 12.17) Previous editions are obsolete. GENERATOR'S INITIAL COPS'