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Please print or type, Form Approved.OMB No.2050.0039 <br /> 2.P a 1 of 3.Emergency Response Phona 4-Manitest Tracking Nurnbar <br /> UNIFORM HAZARDOUS l GeneretOf In Num�b,� � Q 1 g�8 4 8 8 5 J J K <br /> �> WASTE HAZARDS C A C O3 U 2 2 8 6 0 i =4"3f3[764 <br /> 5 Gerreratoes Name and Meiling Address Aft;K 4011416 D I��Biiereraloes Site Address{if different than marling address) <br /> LBB find V14AM frldtld Wl.LLC <br /> 3347 MIttit cion[Voi.St*A 2W S W.3Cht�a Road <br /> bAiril. CA VIX12 WSW. CA 85377 <br /> Generawes Phone: <br /> U.S.EPA tp Number <br /> 6.Transporlar t Company Name <br /> 1 C A R 0 0 0 1 Q 8 3 3 8 <br /> 1. Q AI,lBi1�n�I1[llgP�lifd�uCf[YlC]R5.tilt;. <br /> J <br /> T.Transporter 2 Company Name U-5.EPA IU Number <br /> �} B.Desgnatad Faahiy Name and Silo Address U.S.EPA ID Number <br /> Ct►:shy&CWerbn,Inc. <br /> 1630 W.17111$host <br /> Long Reach CA 9M13 C A D 0 2 8 A 0 9 0 1 9 <br /> FacjWsy Phone: <br /> (' 9b.U.S.DOT Descnphm lmdudkv Proper Shipping Norm.Harald Class.10 Number. so.Canlainers 11 Tota! 12.Unit 13.Waste Codes <br /> 1 Hhl and Pedrktg Group{d any;) No. Type Ouanhty wilvot <br /> If ae 1 <br /> L441 W3,MSTE l=lantl�liWo llgtids,N.C.S-,Cist>Pat:l�.3,FK311 D001 3,31 <br /> 0 <br /> 01 DM 2 G <br /> s <br /> E uj a. UN1769,V*)SIY Hydlvr"lV1i ld,8.Pdll DW2 133 <br /> a <br /> f r- DF oZ G <br /> 3' Nan-R4;RA KIZOW A Wu e,50KO 16Was 6,OX Rh WS) 3.52 <br /> a DM P <br /> I <br /> a V0�67�, WRsTe0 �r•h>+�ton•Cc �vlra��an+�i 7 <br /> T4.Speaal wrdling IrrsUUdws and Additional Inlprmakon <br /> Weal a1:1,t r>p,Ls.at a PPT: whilr- hatsdLitig. WeLghte or vol.unma are approximate. <br /> 9Is proijeci, #39151) <br /> b.1 PL ?file # 9u.2) Profile # 9L.3) Profile # <br /> 15. GERATOR11OFFEROR'S CERTIFICATION: I hereby dedwe OW the conients of This consignment are fully and accurately described above by the proper shipping name,ard are dassi5ed.packaged, <br /> EIi <br /> xmarked and laoefedWpfacarded,and are in all respe ft In proper candllion fpr Uarsport an:mrding Io applicable Irllamabonaf and natonal goverivnental regulabons.If export shipmert and I am the Primary <br /> Exporter,I oafbfy Mthe amlieft of toes consignment collars to the terms of the attached EPAAcknowfedgment of Consent <br /> �u i cerkfy gnat me wasps nYn a1 statement idenbned in 40 CFR 262.27(a){if I aril a large quantity generator}or(b)li(I am a small quanby generator)is true <br /> a Genarapofsi7t[erorsPrinwVypedNam Signature Month Day Year <br /> 0j be is It of GeIwi alar r ,,� 1112 <br /> 16.wernaborw Stupmenm <br /> rr ❑import ioU S ❑Export from U.S, Pat of entryierl. <br /> 1 ? 7ransporler sgnalute(fox exports ony): Date leaving U.S.: <br /> 17.T+ansporl&AckwMadpwA of Receiplaf Mewls <br /> ' a TranapwW 1 Pr'nWyped Name Signalure Month Day Year <br /> � l � r - �� 17112-1 <br /> r z Transporter 2 Pnntedrryfed Namef Slww Month nay Year <br /> a- <br /> 18 Discrepancy <br /> k(i 1 B D+suepan y ind"liul Space ❑O.My ❑Tn. ❑Residue ❑Partial Rwhan ❑Full Rejection <br /> Mamf"t Reference Numlxr. <br />�rn ki <br /> ate FKAily{a Generawl U.S.EPA ID Number <br /> haiaf t:ire ofAnernatte Facripty for Genewor) UAonlh Day Year <br /> 7- <br /> w:kasta Report Managemam)MufAod CAdes(I e..Codes fa hw2rdous waste natmefn,disposal.and recycling systems) <br />,r 2 3 A <br /> aled Faokly Towner a Operaw Carhkation o!rerepi of hatardous matenals covered by te manifest aXCgg as ndad in Ilam 1 ea <br /> ied Name Ignature ManSh Day Year <br /> EPA FWM 9704.22 RRav 12.17) Previous edlhorl5 are obsolete DESIGNATED FACILITY T4 EPA's e•MANIFEST SYSTEM <br />■ ill <br />