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<br />Form Approved, OMB No. 2050 001
<br />EPA Foran t37oU-22 (Re4�1'2-17) Previous editi7s ale obsolete. t ^,� ` DESIGNATED EACILITYTO GENERATOR
<br />UNIFORM HAZARAOWSy
<br />WASTE MANIFCST
<br />1 Coder for ID Number
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<br />7 Page i ofa
<br />Emr rgrncy Response Pyono 4. Made estT ac nfl Nn bor ^y /— - I
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<br />Nanta, r i,I1,Main gAAd�l Caroni Site Address (if tfhterent than mailing atlQmss)
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<br />2323 EASY l LINE RO?kD 9 9ka11 ii fd P,N h+L
<br />RACY`, CA 95304 LfaRo. !:a
<br />1495.1^c,24'1
<br />Gon ell Phone:
<br />S. Transporter I Co ay e
<br />serwiC.E5 wis - U.S. EPA IQ Number�
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<br />7. Trans orter2 Company Name
<br />P P Y 11.S. EPA 10 Number
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<br />8. Daeinnntod Pacll t Nnaly dSi - Idr r U,6. EPA ID Number d4,dli,"ji0(u�J 1
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<br />C3 xt4y, p foil :F'> USA
<br />Facllity's Phone:
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<br />flb. U.S. DOT DescdpHon (Including Proper Shipping Name, Hazard Gland, ID Numbor,
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<br />11. Total
<br />12. Unit
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<br />13. Waste codes
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<br />and Packing Comma V any))
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<br />Quantity
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<br />146pOClal Handling In uUchonemdgddlliOnallMofmallon
<br />�CENERATOR'81OFFDROR'ECFRTIFICATION:
<br />I5. I hereby declare that the contents ofthls canmfamont are fully and a'onotaoly desedbodabove by the proper shipping name, aid are classified, packaged,
<br />marked and labolodlplacamod, and alb in all roepor,L in portion canditim) for tamspdrt'arkeording N applicable iotemationaland national governmental regulations. If export shipment and[ min the Primary
<br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. .
<br />I codify that the wpS1ti minlmlzatlon statement Idwitlfled in 40 CFR 202.27(a) (R 1 am a large quantity generator) or (b) (if] am a small quantity gr.noinlor) is true.
<br />Yangraor's/Cfferor'.s
<br />Printed/Typed Name Signa no 7 Month Dayy m,
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<br />Intomaional Shipments
<br />LJImport to ll.S. ❑L'-xportirom U.S Port ofonhylcwt. �-
<br />I ranzpoderslgnabiro It expands early): - Date leaving U.S.:
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<br />17, TransporterAoknntMcdgmont of Rocept of Motanars
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<br />�e"ISlgnal6(m � Ivlanlh �u �oer
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<br />TransPo�r:r2P do
<br />olg Month say veal l
<br />18. UlscroPancy____
<br />iSa. Discrepancy Inclination Space r l Carroll ._..__ 1'YIa Residue ._ Partial R_o-j.e..c..ti. on Fall Rnjacli0n
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<br />Manifest Roforence NlNumhoc
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<br />18b Alfemata Faolllly (or Generator) - 11.6. EPA ID NumborFick
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<br />i1'Iy's Phone: '
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<br />-1-§-9111t111 -.— Month Uay Ynol
<br />0AJtornnlo FacllllY (or -Generate,) '
<br />Raped andg?met, Metnfd —Codes (Lo., I�rd)fS waste. tfeamfrat, dlBpaa1,
<br />codes—for and rBpyGng 9 ystams)
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<br />20. Dwign ad slilyOwnerof Operator. Ccddcation ofrornlpofha rardous mattaials covered b {he manirest exce ta. de in e18a
<br />Priaed/(yped Name'} - • '� Signature j J � Month DDw Year {
<br />EPA Foran t37oU-22 (Re4�1'2-17) Previous editi7s ale obsolete. t ^,� ` DESIGNATED EACILITYTO GENERATOR
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