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DTSC. • 91 . 2188 <br /> Please print or mm.(Form designed for use on elite(12-pitch typewriter.) Form Approved.OMB No.20504M <br /> Uw�TE�IFESUs 1CAL00011j 52 2.page lof 800 Response X472 4.®152 N3220 JJK <br /> 5.Generata's a and Mau Address A%,b I R®RE MBNA GeneraWs SiteAddressff different than mailing address) <br /> 0 17 <br /> p O5 3o 240 5S M5 ;?0'# �C.58 W WTO MC I NTT NS' IND <br /> ON LANO CA, 4t 6287— S5 CLEM S, CA 14522'7 <br /> Generaloes Phone:Or S6.Transporter 1 Company Name U.S. :PAIDNumber <br /> /VG. E'NVIa®N '5NTAL SE GES ICAEOoo0 3101f <br /> 7.Transputer 2 Company Name U.S.EPA ID Number <br /> v L1l--G GTS ro J' �- <br /> B.B. nate$vdy�magd,St� dress I1�� U.S.EPA ID Number <br /> 1(030 W. i74ti SI E& 'V <br /> EONC-196ACH., CA q O s 13 <br /> FaalitysPhone: 5e.L` 4372" 5445 1 CAD021940 of l <br /> 9a- 9b•U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNol. ^� <br /> 1.Al" C A t-AO-ZAfkC061115 , 90LI I> <br /> 0 (EMPTY,LAST COWTAI N6D ?M55ItM nht4A1%hN CTt) <br /> 001 Im 0 b$p P <br /> LU <br /> 2 0 - R P1DOVg S i 5 '2. <br /> " (Ef"I 11WCOIJAIKED OIL) <br /> 601 IDM ouzo � <br /> 3.JVh 3077,YYPRST6 AZAR ®v S was-r!,SOL t D, . DO S a <br /> cMt�`rA�.sHAvt►vGs),'R,PGcti (t\4�oog) ® F 000 5 P P66"71 181 <br /> 4. <br /> 4,Special Handling InsWcdons andRural In rmation <br /> TO / <br /> P F1"E 1,3 6°6 2) 3Lt606 (350� 3 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper dipping name,and are classified,packaged, <br /> marked and Iabeledtplacarded,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)(d I am a large quantity generator)or(b)('if I am a small quantity generator)is We. <br /> Gencrato roc's Pdn Name Signature Month Day Year <br /> Ilk <br /> 16.InternationShipments <br /> I— ❑Import to U.S- ❑Export from U.S. Put of entry/exit <br /> z Transporter signature(for exports o*y Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter t Printed/T,, Name _ Signature MonthG Day� rYear <br /> r <br /> ca03 <br /> Transporter 2 PrintediTyped Name Si atur Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Residue ❑Partial Rejection ❑Fut Rejection <br /> RECENED <br /> Manifest Reference Number. <br /> 18b.Aftema;a Facility(or Generator) J uh lV 2TTUTF U.S.EPA ID Number <br /> 6� <br /> W Facility's Phone: <br /> 180 Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> a19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycing systems) <br /> G 1. 2. H \� ' 3 r14 ( 4 k 4. <br /> 20.De—sigii6d Facility Owner or Operator.Certification of receipt of hazard materials covered by the manifest except as noted in Item 18a <br /> PdntWyped Name Snature Day Year <br /> qjj 114 <br /> EPA Form 870022(Rev.3.05) Previous editions are obsolete. DESICs FACILfrY TO DESTINATION STATE(IF REQUIRED) <br /> 12382.0823 <br />