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f• <br /> ase pent or type. } <br /> Fufrll Approved.0M No.250.0039 <br /> UNIFORM RA2.ARDWS 1 Generator iD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number p <br /> WASTE MANIFEST C A C 0 0 3 0 2 2 B fi 0 2 tat"3 019X16 4 8 8 4 JJ K <br /> 5-Generator's Name and Mai%ng Address At KAileen LedhoftePeneralor's SlW Address(if diAetenl than mailing address) <br /> UM FW1d MV1A Indi,4 Tlai,LLC <br /> 33471 iiratw D&e.Sw,h 200 14 0[)W.Scitiulto Road <br /> lnrir Q- CA 132612 TMOY, CA X377 <br /> Generator's Phone. 94 9 6 6 A - ft ❑ 9 3 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AmMkAl►11i ftlalted S tildloes,Inc. C A R 0 0 0 1 4 6 3 3 S <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address US EPA ID Number <br /> Cmd)Y'$OVaiibn.Inc. <br /> 1630 W.i 7112 fttlet <br /> Long uach Cil 9[16i3 <br /> Fala[W521101W 6W 4324A45 C A D 0 2 8 4 0 9 0 1 9 <br /> 9a 9b.U.S:DDT Description(including Proper Shipping Name,Hazard Clus,10 Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Gawp(it any)) No. Type Quantity VVI.Nol. 13.Waste Codes <br /> o ' Ut 1490,VASW—AeroWk,2.1 DWI 331 <br /> DM P <br /> lt.li'fVW,VWt=Coi>to l Igldd,Basle.Inor6i►nle,PI.O.S., C 3� D00 141 <br /> (Sodium I'vdroid&),S.PCNL <br /> C; <br /> 3. 1JI411332,VASA,6ulturic Arid,Spent,r'3,Pail �� � 5� DOO 133 <br /> G <br /> a. Nall.-WAA liamtt*Gus Wale,Llgtjid ftlkauIleX Ning 011) 221 223 <br /> 14.Wel Handling ltts'bxdons and Additional Information <br /> Wear al -ni3p�riaL-e PPE while handling. W il.9htr3 or volunaes are approximate. <br /> ikTS Pro1ect 13915 <br /> 9b.11 Profile 4112402 9b.2) Profile 11105831 9b.3) Profile r <br /> 9b.4a Profile 494159 <br /> 115 GENEUTOR'SlOFFEROR'5 CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are Gasified,packaged, <br /> ranted and labeledlplecarded,and are in all respects in proper oonditien for transport according to applicable intemationaland national.govemmenial reguiarons.K export shipment and I am the Primary <br /> Exponer,l certify that the contents of this consignment cordorm to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify 1*the waste minimization statement identified in 40 CFR 262.27(a)if I am a large quantity generator)or(b1[8I am a small quantity generator)is true. <br /> GeoeratorslOfferors Pnn4dfTyped Name SgnManlh Day Year <br /> 0n bel talf of Goneivtar alure -7 1 j <br /> 116 Intematiorld shipmerns <br /> F ❑lmpdr!to U.S. ExpoR from U. Port o1 enhylexit: _ <br /> Transporter signature tlor exports only): Date leaning U.S.: <br /> � f7 Transporter Acknawledgmenl of Receipt of Materials <br /> Transporter 1 Printedrry*Name Signature Month Cay Year <br /> Transporter 2 Pnnledffyped Name Signature Month Day Year <br /> i <br /> 18.Discrepancy <br /> tsa.Dwepancy Indication Space ouantity, ❑Type ❑Residue ❑Partial Rejection ❑Full Rejeclwi <br /> f Manifest Reference Number <br /> 18b Allemate Fadfity(or Gernerawr) U.S.EPA ID Number <br /> Ci <br /> Faratitys Phone <br /> 18C signature of pllemate Facility for Generalor) Month Day Year <br /> a <br /> x <br /> 19.Hazardous WasW Fteporl hhanagarnenl Method Codes(1.6.,codes for hazardous waste IrBatmenl,disposal,and recycling systems) <br /> a2 a•UJ <br /> a <br /> ■ G <br /> Catuntim of receipt of hazardous materials covered by the r ifesi except as nded in Ite <br /> 26,DesgnataC Fatality Owner aOperator- m ilia <br /> I Pn� YPed Nam Sbgnatu a Month Day near <br /> 1 } EPA Farm 87DII-22(Rev 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> %1k_ <br />