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Please print or type- <br /> FormApproved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 tar 1D Number 2.Pae 1 of 3.Emergency Response Phone 4.ManlFest Tracking Number <br /> WASTE MANIFEST �+!000 L/. � ? 1 � SF?-e L/���qya 020427517 JJ <br /> 5. neralor Nameranndd Mailing Addr Z_L <br /> Generators Site Address[!f dillarenl than mailing address] <br /> a- G ZSR <br /> Gv w c4_ 2eq 1330 lv cry 97 <br /> Generator'sPtiene: �y �In - Me �- yo7 Z p,D!1 CA. 9�S o <br /> 6.Tl�n�r�l�T&7 Lg . Inca j� y� <br /> �] �s.�A�N�beo 0 2 1 7 5 1 3 <br /> P <br /> any NameU.S.EPA ID NumSite Address U.S.EPA ID Number <br /> a AV9n6iFB <br /> elloamk#on CA 92395 <br /> Facility's Phone: 909 421`2012 C A ID 8 2 4 $ 4 4 8 1 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> n r , • �,� No. Type Quantity Wt.N01. <br /> O <br /> Lt 4—A) 6 Y <br /> LLJ <br /> PA <br /> 1?-C)Z4 r2da�S GJt�3 ! i ZS- <br /> - <br /> S- <br /> (Gf9 Me-Z S4 -a1) o o <br /> 1 Special Handling 1 trucGans and dillonal Information <br /> l 1u pt4- e'L ILL s13) 4} III.(&S LIP <br /> z}0 tt L l K��) GvOf. .S�o g�'2 <br /> x ,fox <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 labeled/placarded,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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 282.27(a)(if I am a large quantity generale)orb dI am a small quantity(}(' q ty generator)is true. <br /> Generalorsl0ffe5yp Name � SIgnalte Monlhas Year <br /> 16.lnlemational Shipments <br /> 7 Za <br /> Z ❑Import to U.S. ❑Export T S. Port of a xlf: <br /> Transporter signature(far exports only): Date of <br /> U-S.: <br /> 17•Trans porter Acknowledgment of Receipt of Materials <br /> Transporter f Pn15>V Uame Sign re Month Da Year <br /> 1 Gv ;-7- <br /> 7 �o <br /> 2 7rarrsparter 2 Prinledlfyped Name Signature <br /> Manlh Day Year <br /> W <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Gertei; ) Manifest Reference Number. <br /> U.S.EPA ID Number <br /> V <br /> Ev <br /> ' ne: <br /> Jui re o[Allamata Faallty(or Generator) <br /> Q Month Day Year <br /> LUs Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1_ 2. 3. 4. <br /> ed Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Name Signature <br /> Month Day Year <br /> EPA Farm 870O22(Rev. E2-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />