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CCr ! 41 ' NTP # ?r^F, � 4lt � � `�r 1/ �/ � II � IIIIIIIIIIIII�IIIIIIIIIIfIIIIlII�I <br /> 0067761063 K3 <br /> Please print or type . Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number h r ;;, 2 . Page 4 of 3. Emerg@ncy Response Phope 4, Manifest Track in ]Number �[ <br /> WASTE MANIFEST 0067 1 6106 S K (V <br /> 5. G@q a VA¢Q a `, nr Generators Site Address (if different than mailing address) <br /> iTEM -iVl , I ` i <br /> SAL IDA CA ^, ` k;rpt* <br /> T !2119 - 54i` — 10 1 1 SAL I DA <br /> Generator's Phone: <br /> s. Tregp , orlert "PePYj PM SYSTEMS INC U . A N r <br /> 7. Transporter 2 Company Name GPA ID Num <br /> 8. Designated Facility Name and Site Address `o ( r_ 'r " - OF UALAIVUHNIH U .S. EPA Nu ber <br /> 6E' po chtl ": f { n ',) F . F,Q?' 2j� �J <br /> NFIeWRIK <br /> S1AV! <br /> Facilitys Phone: <br /> ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 Total 2. <br /> and Packing Group (if an Quantic WI.NoI , <br /> 13. Waste Codes <br /> HM n9 P Y)) No. Type Y <br /> o ( 115OFn OTI - ) <br /> z z. <br /> w <br /> c9 — <br /> 3. <br /> 4. <br /> 14, Special Handling Instructions and Additional Information 1 V GciA !- <br /> : ! 1 r >- PIF `� J! � f �1 . 4c, P. • 17GOr gC; I-! 9K / T ! I - (: . unirAct, rei.: � inr by gzjnerl t. nr, t. r) rtc r , , : q , : 1r_cttrirI <br /> r. uiti - I f, t ~ . Tt � Aut ' + : r to arild 13v- s +.tbst ` ti ' Ve ,> c! r! i { jr� tr + ? ` F+ t _. �tOh' i; er~ �, nil rgr• nii! r ;if, ! - ►� ,- 1 <br /> 15. GENERATOR'SIOFFEROR'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 labeledlplacarded, 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) (if I am a large quantity generator) or (b) (if I am a small quantity generator) Is true. <br /> Ge toes/Offerors Prinled/Typed Name Signat Afonlh Day Year <br /> � 111 113 1 19 <br /> l6i'"Eternalicipj Shipments <br /> OF <br /> F ❑ Import to U.I. ❑ Export from U.S. Port of entry/exit: <br /> ? Transporter signature (for exports only): Dale leaving U.S.: <br /> W 17, Transporter Acknowledgment of Receipt of Materials <br /> UJ <br /> Tran iter 1 PrintedlTyped Name Sign eMonth Day Year <br /> LL oLft Tai (orC . 7- 3 I le <br /> Z Transporter 3JnntedrTyped Name Signature Month Day Year <br /> 18, Discrepancy <br /> 18a, Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Altemate Facility (or Generator) U .S. EPA ID Number <br /> J_ <br /> V <br /> La.. Facility's Phone: <br /> w 18c Signature of Alternate Facility (or Generator) 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 /> 0 1 � n 2. 3, 4. <br /> 20. Designated Facility 0 vner or Operator. 'Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> Printed/Typed Name Signature f. onth Day Y ar <br /> EPA ofq 11p1Q,2 Sot f 17) Previous ditions are obsolete. U EPNATED FACILITY TO EPA's e4v1 <br />