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• <br />Please print or type. (Form designed for use on elite (12-0, <br />T <br />IFFOORM HAZARDOUS 1- Generator ID Number <br />WASTE MANIFEST CAL0002W421 <br />I AdwK*d ChwWced Tampoll Im. (SV) <br />• <br />Form Approved, OMB No. 2050-0039 <br />er <br />m= 0088Nitst 27010 FLE <br />0. Deslgnafed Facily Name and Stla Addross U.S. EPA ID Number <br />M �` "` KI i MAN S Beaty NvFa3ooiac>oa <br />Sea ty, w <br />Faditft Phone: 7?5 653 �22i13 <br />go. 9b. U.S. DOT Description (including Proper SNppug Name, Hazard Class, ID Number, 18. Corers 11. Total 12. Ung 13. Waste Codes <br />HM &W AWft Group Cd awA) Ab. Type Quantity WLNbl. <br />1CF P 331 <br />NA& Okeam.01244 IMMOKO•9, PG M33 <br />—z-- CF P - <br />14. Special Handling insbudoos and Adftnal Information <br />Pteljwt Number 7'8'9447 Doa wet * #: DMw <br />1XM* OM315Ml1&QGKk eXW =131Mll=08U- <br />15. GENERATORWFFEROR'S CERWICATION: I hereby declare Ilial the contanls of this crosignment ale fuly and accaaately described above by Pre proper udrong name,and are dassified, packaged, <br />merited and labeledipiacanded, and are in all respects in proper condition fortransport scoorfg to applicable pNernational and na8arel govenarental reaulations. If export shipment and 1 am the Primary <br />Fxporter, i certify Prat the contents of tlriss consigrmrerd conform to the terms of Pre attached EPAAcknoMectgmerd of Consent. <br />I oernly that the waste minimization statement Identilied In 40 CFR 26i2.27(a)(if I am a lace quantity gwrAW or (b) (i11 gn a small quantity generator) is We. <br />Gatop erors ypedhaOhbnth My <br />� QE1 %+ il� a Ql� O!—' <br />8. in <br />❑ kr t to U.S. ❑ Export from U.S. Port d entrylexti <br />Transporter ss wilure (for -ports only)' Date leav"rg U.S <br />17. TransporierAdorowledgment of Receipt of Materials <br />%c I Y- f> <br />18. Discrepancy <br />18a. Discrepancy Indio Space ❑ ❑ Type ❑ Residue ❑ Partial Re) d. ❑ Full R*d. <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA 10 Numtw <br />V LL <br />1:-00. ph m. ' <br />y 19. Hazardous Waste Report Mwwgement Method Codes (i.e., codes for hazardous v0sto traetrrtent, disposal, and recycling systemA <br />G <br />lt'D <br />3 2. 3.. <br />20. 6e#gimedl Facihty Owner or Operator: <br />C�{erficabon of meeeelpt ooff/h_aazaarrdoo)uss mmaaaterialss�oweerred by dre mardest exoept as noted ki Kern 18a <br />PrHrt � 1 tt � 1 1 it L+ A i i.!✓ t._]� T i � S�turo /} <br />FACILITY TO DESTINATION STATE (IF REQUIRED) <br />