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l <br /> Please print or type,(Form designed for use on elite(T�2,plieh)I pawritec) ' C' v;:r) DE � � <br /> UNIFORM HATAI'.DOUS mbe 2,Page i of 3.Emer ency Resp.n o phone 4 ManIt t 05Tracking Numbar t' 050.0039 <br /> WASTE MANIFEST t.Generator lD N f Yt S ut fl r r "(t J g{ Rr t ,+ dorm A �oved,OMB No.2 <br /> 5.Genaratoes Name and triailingAddress � "� .- o-1 3 9 SKS <br /> f = Ganerator's Site Address(if diffefent than mailing address) <br /> l r <br /> t {ut:) <br /> Generator's Phone _y 1 +•}t`} +a�e J = <br /> G.Transporter 1 Cc any.Name <br /> i=C-FY nl.:.~�.EN 8YH w � q) U:5.EPAiDNumtier <br /> ( r? � 1Vv. <br /> #t iio0itty 4 j;:!t <br /> 7.Transporter 2 Company Name � � <br /> U.S.EPA ID Number f <br /> 8.Designated Facility Name and Site Address I " <br /> frill jbom ).:.#;.c t U:S.EPA IDNumber <br /> ROAD.. <br /> CA .95-13 <br /> Facility's Phone: <br /> 9a, 9b.U•S.DOT Descilptlon(including Proper$hlpp g Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) 10;Gontalners ji,Total 12.-Un11 <br /> No. Type Quantity WIJVOI: 13.Waste Codes <br /> 1 �O `i(kR � �Z17A # 1aO#1S W91S t✓ SOl,1;15%: ; <br /> w 2. <br /> c� <br /> i. <br /> 4, j r <br /> 14.Special Handling Instructions andAddillonal Into all <br /> T 311)S A 7-64,9 CSQ 4 <br /> HR EMERGENCY #I-A-00-4 7N <br /> I f; <br /> 15, GENERATOR'31DFFEROR'8 6ERTIFICATION:I rte eby declare Ural the contrynib of Uiis con@Ignment are rull y and accurately desenbed ahbva by,ilia propersh#pping Hama,ar 9 are cipssified,Packe9e <br /> marked and labefedlpiacarded,and ara in alt reeRects n proper condillon for trertaporlc�r ng{o_ppif ca�le.(n a Allonal aPd Haftona�:goveminentatreulat{aits;if.ezp'ortsh(ptnant and i am the Ptlma . <br /> Exporter,icetiify thatihe contents arIli s conslgnmeltt1conform lo:ihe forme of the alt�gF)s pAAckftotvledgil g f'Consent:. ry <br /> I een((yltiaf-the.wastom1him zati 61 lemantlddniilla .in 40 CFR 282;27(x)(tf t.'ZO tge gLartiilyyeparator or:(tf)(ill arp a: ti puantity g 0h <br /> tor)is iNe <br /> n alorslOffararsPrin(etl/Type arna Sg <br /> t ( ', Mdnlh Day Year` <br /> -i- 18.Infemallonal9Mpme t <br /> f ❑Impart to U S:- ❑Export from U.S. Po afegiry/ex(C. <br /> Transporters(gnalure.RAxports only); . <br /> Daleleaving VS.: <br /> U, <br /> 1Z Transporterkcknowledgmentol'RecoipFofMatedals <br /> Transp. Frintedlfyped Name <br /> p i Signa{re Month day Year <br /> v' <br /> Transpo{fe nnte pad,ame - ignat re <br /> 1 Month .Day Year.: <br /> 18:Discrepancy <br /> 18x.Discrepancy Indication space I <br /> 0 Ouang n <br /> N j t_1 TYPe I_{Residue Pad<ai ReJact(oil Fui(Rejoction <br /> 18b.Alternate Facility(orGenerator) Manifast Reference Number. <br /> EPA ID Number <br /> LIZ Facility's Phone; <br /> w 180.Signature ofAllemsta Facility(.,Generelor) <br /> Z Month- Day Year <br /> 19.Hazardous Waste Report Management Method Cod's(I, ,,codes forhazardduswaste trealmant;disposal,,andrecydingsystenu) <br /> i. 2. i <br /> 20,Designated Fa6lity Owner or Operator.Certification pf redaiptof hazardous materials covered by the man)festexcept aspcted in item 18a <br /> Printed/Type Name <br /> w r S(giia(ure y <br /> (llonth Day Year <br /> EPA Form 870022(Ray.3.05) Previ`s e Itio�ra.�bso ere. <br /> 1 )74 �;/7 u ( �,r4" RIGNATEd FACILITY TO G NERATOR <br />