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11 <br />Please prior type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Annrnved OMR Nn gnFn-6ns4 <br />rrM roan o(uu-« tnev. a-uo) rrevious eumons are oosoieie. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />IFORM HAZARDOUS <br />1 • A erator Num <br />2. age 1 of <br />3. ag cy s o ne <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />/ .o✓��-` <br />003336227 JJ <br />5. Generator's Name and Mailing d res4 / Generator's Site Address (if different than mailing address) <br />AKellv <br />.r Phone:% <br />E� <br />6.Transpo', P9'6WEnvironmental Services � � � 13262 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address vej y i eu i I Of 1, 1 ri c. U.S. EPA ID Number <br />6880 Smith Ave. - <br />Newark, CA 94560 CAD980887418 <br />Facility's Phone: 510-795-4400 <br />9a. <br />9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />10. Containers <br />11, Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />Quantity <br />Wt.Nol. <br />1. <br />' 1� <br />O <br />0 <br />—bow TUL <br />w <br />3. <br />- <br />4. <br />14. Special Hand'ng Instructions and Additional Information ._. <br />Lal <br />15. GENERATOR'SIOFFEROR'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 />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 />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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) (if I am a small quantity generator) is true. <br />Generator's/O/ffferrors Printed/Typed Name Signature 107 <br />✓fMonth- /Day Year <br />e"-- <br />A <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. ort of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. TransporterAckno dgment of Receipt of Materials <br />O <br />V) <br />me Signature Mont Day Year <br />Transporter i-C.E_� <br />Trans iter rinfed/TypedName nature Month Day Year <br />t-- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity Type ❑ ❑ <br />❑ Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />LL <br />Facility's Phone: <br />U0 <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLJ Q <br />L <br />2. <br />3.. <br />4. <br />Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Name Signature Month Day Year <br />nd <br />rrM roan o(uu-« tnev. a-uo) rrevious eumons are oosoieie. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />