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ll-t S C 2 S-�- Fj <br /> A-7^ <br /> Please print or type.{Form designed for use on elite(12-pitch)typewrites) Form Approved;OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 7oOl 3.Emergency Response Phone 4.Manifest Tracking NumberWASTE MANIFESTIllf <br /> �g28'�1 -��-�7�D ®®4 0 ^ 5 JA <br /> 5.Generators Name and Mailing Address Generatots Site Address(if different than mailing address) <br /> LLOMM O X11 LUMPAMR8 033 <br /> oto Ra do bv ft=2W 4M MOM AVEMSE <br /> M=n,0H4W"i16 ST C),CA SM <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> g ra 01e00a 22212 <br /> 8.Designpattepd Facility Name and Site Address U.S. <br /> U.S.EPA ID Number <br /> AM MOSM83 <br /> RRO1 1123391 <br /> "(34129 <br /> Facility's Phone: <br /> 9a. 9b•U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.co ainers 11.Total 12.Unit <br /> HM a�ndd/rPaackkiingg Group(if rrroue(if aenyy)) No. Type Quantity WL/Vol. 1037.Waste Ones <br /> . Q � 1•VVWUI4W U1::+7tllYeVVG.1161.�.N U4�sf VW®af7O I V�9 0 k{LUV U�JOo {t RIF � NJEiS IY,.Y�Yrtl <br /> 1 <br /> 2 2. <br /> W <br /> f <br /> 3. <br /> ) <br /> 4. <br /> 14.Special Handling instructions and Additional Information <br /> 1.) r Vjd 0:4 ;SAID 01 W <br /> 15. GENERATOWSMFFEROR'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 labetedfpiacarded,and are in all respects in proper condition for transport according to applicable intemational 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 terns of the attached EPAAc knowledgment of Consent. <br /> I certify that the waste niinknization statement identified in 40 CFR 262.27(a)(d I am a large Quantity generator (d I am a ser 8 u Intily generator)is hue. <br /> GeneratorslOfferoes PrintedlTyped Name S' Wre Month Day Year <br /> (- 0 <br /> J 16.International Shipments <br /> �import to U.S. El Export from U.S. P4 of enhyfexit <br /> Z Transporter signature(for exports only): ate leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> a Transporter 1 Printed[Typed Name Signature ar <br /> Month Day. Ye <br /> Transporter Prfntedfiyped Name Signature Month Day Year <br /> il -X- 10 <br /> 18.Discrepancy IV <br /> 18a.Discrepancy Indication Space F� Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> C,2 <br /> Facility's Phone: <br /> Lu 18c.Signature of Aftemate Facility(or Generate) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdntptd Typed Name Month Day_ Year <br /> EPA ForrWMO ev.3-05 Previous e sareobsolete. SIONA ED FACILITY TO GENERATOR STATE(IF REQUIRED) <br /> 10341.2171 <br />