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MEM <br /> Please print or type. (Form designed for use on elite (12-pitch) typewriter.) _ Form Approved. OMB No, 2050-0039 <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Pagel of 3. Emergency Response Phone 14. Manifest hacking Number �� <br /> WASTE MANIFEST CAL 0 0 0 4 0 '-' "Z ( 3Cri�14 X1- 93001 011178629 <br /> 5, Generator's Name and Mailing Address Generators Site Address (if digemnt than mailing address) <br /> AGAMA K <br /> 70"M S, Lt_ NG-E ST. <br /> STOC)c 1ON' CA 85200 <br /> Generator's Phone: ( 213 234° o i 6`�' " <br /> 6. Transporter Cam any Name <br /> - U. AIO Nur�hefm®2e3w fi? <br /> 7. Transporter Company Name U.S. EVA 10 NUI <br /> B. Designated I .- 1, Name and SileAddrass U.S. EPA ID Number <br /> CHEMICAL 14fA8TE 10Aillr'BEMENT, INC , <br /> ki ILGt SKYLINE POAd� T ti C e 1 1 i <br /> KET f'LERIIA V CITY C-A 93%2249 <br /> Facilitys Phone: ( 5u) 3867" 879 ! <br /> 9a. 9b. U.S. DOT DecNipVon (including PmperSMpping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Units. 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WLNI ¢¢¢¢ <br /> a NON RCRAHAZAPIi E £OLIC ® � 489 <br /> M 2. ',.. <br /> 4. _, — �.....� <br /> % fipecial Handling lnstmctionsandAddNonal Information - � . t'1 O➢ ..f �1���C'%dD ,���l3P . ��� ',. <br /> CHEMTPEC CONTRACT 4.CN24. 117 ��q� '2IIPI <br /> 15. GENERATORSIOFPEROITS CERTIFICATION: Ihereby 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 lobeledlplacarded, and are In all respects in proper condition for bansp nt according to applicable international and national governments[ regulations. If export shipmenland I am the Primary <br /> Exporter, I cedity that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste mindimboullou 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 bud. <br /> Genemto r4igr's Pri ped e� F Signature Month Day Year <br /> h 16. International Shipments L-limpart U.S. LJ Export from U.S. Port of enby/edt: <br /> Transporter signal ire (for exports only): Date leaving U.S.: <br /> K 17. TranspoderAcknowledgmentofReceipt of Materials <br /> W Month Day Year <br /> Transp Pd tedR ed Name Signa <br /> O <br /> C Transpo r2 Printedffype Name Signalur Midith Day Year <br /> f-- <br /> 18. D[screpancy <br /> .18a. Discrepancy Indication Space ❑ quantity ❑ Type El Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> Um. Alternate Facility (or Generator) - U.S. EPA ID Number '.. <br /> J <br /> U <br /> Facilities Phone: <br /> Month Day Year <br /> file. Signature ofAiternate Facility (or Generator) <br /> Q <br /> 19. Hazardous Waste Report Management Method Codes Cia., codes for haurdouswastetreatment, disposal, and recycling systems) <br /> 3. 4• <br /> 20. Designated Facility 0vwu r or Operator. Cedifim[ion of receipt o hazardous materials covered by the manifest except as noted in item 18a <br /> PrimedfTyped Name Signature M nth Day <br /> EPA Form 8700-22 (Rev. 3- Previous [tions are obsolefe. ®Ea8�6tti'ifaT�® �R�9F,�g� g e�T61UATB®�f STATE III <br />