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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Forfn Approved , OMB No2050-0@38 <br /> UNIFORM-I1AZARDOUS 1 . ranerator iG Number Y PFyo fof 3 . Emergency Response Phone 4. Manifest Tracking NumNumbor1 . <br /> WASTE MANIFEST . C ��A z 0 0 0 2 5 ' 2 7 ! jF l) 42 0,-M ..O J ��@� <br /> 5 Ceporotoes Name and Mailing Address Generator's Site Address (if differentthanmailing address) <br /> 0A 01IRYR WESTERN MOTOR _- CA,S€ VI <br /> P.k <br /> Generator's Picone; ' t �BAli C 0. ; u r <br /> 6. Transporter 1 Company Name U.S. EPA 10 Number I <br /> WORD MRIMo ENTAL SEP110E 4 I C A D k) 22 3 2t't <br /> 7. Transpoder2 Company Name U.S. EPA ID Number _ <br /> 8. Deeigneted Facility Name and Site Address U.S. EPA.ID Number <br /> DENiEA3NNO / K{ErKC'OON <br /> h/gyp gg411 i lta'1 : t^t J.•} ,: - <br /> FacilitynPh6ne: f317)a37- 7iW _ <br /> ga 9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 , TOW 12. Unit i3. §Vesta Godes <br /> HM and Packing Group (if any)) No, Type Quantity Wt.Noi. <br /> VVA`f ER)r 3t n4 11 <br /> i <br /> 2. <br /> s <br /> 3. <br /> 1 <br /> 14, Special Handling Instrugfions and Additional Information <br /> CzMERGZNO`I' CojwrAG, : CHzi'VITREC 1-8004241-497300 IVYOE7 TERMINAL: CER158 CS NAERG;Y 581 : 128 " PROFILE ; 38g. <br /> 356041 GNSO DIESEL, WATER APPROPIRATE PERSOVAL PROTECTIVE EQUIPMENT J �? �� <br /> (7 rig �t� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by fhe proper shipping name, and are classified, packaged, <br /> marked and labeledfplocarded,and are in all respects In proper eonditlon for transport according to applicable international and national governmental regulations: if export shipment and I am.lhe. Pdmary <br /> Exporter, I carlify that contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. <br /> r I ' i t t the waste minim¢ation statement idenfified In40 CFR 262.27 a if I am a large uant <br /> fytl a { ) ( g q ty generator) or (bf I em asmail quantity generator) is Irue. <br /> Gerg3raloesiOffar' is Printed/Typed Nar d- S na 'te J Month Day Year. <br /> ;Zt A�a7t/ IZ;<` LPZ <br /> J 16, InteAtional Shipments ! <br /> t- n IrApart to U.Sre ❑ Export from U,S. Pod of er trylexih <br /> '`— Transporter signature (for exports bnly): Data leaving U.S.: <br /> u 17. TmnspoiterAcknowledgment of Receiptof Materials <br /> Trans df el 1 PrintedyEY <br /> T ped N e , Signature / Month Dayn Yeas <br /> CL <br /> Z Transporter Printedflyped Name Signature f/ Month Day Year <br /> < iJ <br /> F- <br /> 18:.Dfscrepancy <br /> 18a. Discrepancy indication Space El Quantity D TypeJ Rejection <br /> ❑ Residue ❑ Partial Rejection El Re action <br /> Manifest Reference Number, <br /> 184. Atemate Facility (or Generator) US. EPA ID Number <br /> a <br /> 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 Q.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 2. 3. 4. <br /> 2 Designated Facility Owner or'Operator; Certification of rgceipt of hoz ¢dons materials covered by the manifest except as noted in item r <br /> Pr hted LoName ( Signature � Doth Year <br /> 'o# <br /> EPA Farm 8700-32 (Rev, 3405) Previous editions are obsolete, D t'dNATED FA'CI1.I�''r`�T'O GENERATOR STATE (IF= REQUIRED) <br />