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Please print or type. P- A---1 MAD nl, Ong() nn2n EPA Form uii (Rev. 1L-1 t) Hrevious editions are obsolete. GENERATOR'S INITIAL COPY UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emftjgcy Response Phone 4. Manifest Tracking Number WASTE MANIFEST 1 +�fti ��w " JJ K 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number FIV . i' iR ;E RECOVERY SERVICES ?17: 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number i,:,:.tj,C)VERY SERVICES :3.1.50 F'AS'T PJC0 BLVD,, I ^It (C i:. E.l y 1 90023 Facility's Phone: 499-7141, ga, gb. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13. Waste Codes No. Type Ce X 1.,.lEa► ;t;, tAAStt. FLAMMABLE SOL10S, OR,GANTC, N.0 0001Qx?)3 , o (A(,EFONE. � 4 1.,_ P611, RQ (0001 - W L <: 2d.i#d:l.?3cG'�, WAS'TE AEROSOLS, 2.'l. rt?r;;'l�. ,f141 C 3.N if ,IN RCF1'A tiEl"e.'f'sRDOIJS i SOI.A.'A) (Bi,)Nr 0 Eltj_� I") tai 4•No N 1�("RA HAZARDOUS WASTE.;: La:Qi'J:rD (WA l-E`t;;BORNF C: LEANING SiaL(.1'f:�.CN) (CAI.J-,F(.'lRN1A REGULATED ONLY ) 0M 14. Special Handling Instructions and Additional Information ..I. - ,I sl' I r,)._ ."?i 'Jb2 ) AES'# E74(W.) Sib ) 6402 Q`L„ 4 ) A P # 63 3`a ;1( -VES, GOGGLES & PROI-E:CTIVE (J.0'rl•ING 24FIR EMIER.c:t[_IvCY CONT CJ. r<:fERK WAI.(}0RF RG * 9M.)133 Fodor: ) 1.26 9b3)NONE- 5?d�4 'NION+E RAf��Si>raE;.�.. I .T'R� yI t�I�E _ „5 _ ' " , :34 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the shipping name, aryl are classified, proper packaged, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. Generator's/Offeror's Printed/Typed Name Signature Month Day Year 16. International Shipments Import to U.S. E]Export from U.S. Port of entry/exit: Z❑ Transporter signature (for exports only): Date leaving U.S.: W LU 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O Z Transporter 2 Printed(ryped Name Signature Month Day Year H 18. Discrepancy 18a. Discrepancy Indication Space Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J v u< Facility's Phone: w 7-1 18c. Signature of Alternate Facility (or Generator) Month Day Year a Z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) c 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form uii (Rev. 1L-1 t) Hrevious editions are obsolete. GENERATOR'S INITIAL COPY