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Please print or tvt)e. (Form desianed for use on elite N 2-nitnM tvn,-.writp.r I C <br />rr/-% ruriii OIVU-44 IM8V. J -UO) Previous eamons are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />Page 1 of <br />3. Emergency Response P.,h.. <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />A L 0 0 0 7 8 <br />1 <br />12� <br />1 <br />800 1=t 1*114 <br />1 <br />008369481 JJK <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />"1 L.0 1 3 P AV EL C EN 1-1 'U'L L. Y MARL 0WE P I LOT ' 4 �b- 17 <br />NO X V 1 T N _3797C.1) 15 100 N T HO R N T 0 <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S, EPA ID Number <br />3 <br />T Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />--'ViiE N N 0 K ER D M'N <br />2000 NORY14 ALAMEDA ST. COMPTONIz CA. 90222-2799 <br />7 T 0 8 0 0 3 3 5 2 <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />wtjvol. <br />13. Waste Codes <br />No. <br />Type <br />1 <br />U14 19 r� 3 WA JFTE FLAMMABLE LA1QlJf0, N.O.S. <br />1134, 1 <br />SO' ' <br />r CE... b _1 E L <br />LU <br />TMIS WASf E STREAM HA BEEN 1,18A.1 8v <br />W2. <br />FOR RECYCLING/TREATMENTS AT THE <br />DeMENNO / KERDOON FACILITY IN COMPTON, <br />3. <br />CALIFORNIA. THIS FACIL117Y HAS THE NECESSARY <br />PERMITS TO YOUR �NASTIE STREAM AS <br />.... <br />4. QUAtIFIV. bbil EPANIr. BER IS <br />14. Special Handling Instructions and Additional Information <br />APPROVAL 0- AP -OPRIATE HE SP I RA <br />:24' HOL(IR' E M E R V_ NC y C TJN'." A C T <br />�-FIFMTPEC 800.4-2 -TOO <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, arid are classified, packaged, <br />marked and labeled/placarded , and are In all respects in proper condition for transport according to applicable international and national governments[ regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ifI am a small quantity generator) is true. <br />GTtor's/Offeror's Pn'ntWfTyped Name Signature Month Day Year <br />+ <br />IZ; <br />_j <br />16. International Shipments'XI <br />0 Import to ❑ Export from U.S. Port ofentry!exit <br />Transporter signature (for exports only): Date leaving U.S.: <br />LW <br />U <br />17. Transporter Acknowledgment of Receipt of Materials <br />Ix <br />0 I— <br />TransportgM Printed ped Name <br />11 ASignature Month Da, ye <br />-- -� -- - -C-Z,:, <br />IL <br />rn_ <br />_- <br />ZQ <br />Transporter 2 Printed/Typed Name Signaturk Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space aQuantity ❑Type I EIResidue EIP.M.1 Rejection Full Rejection <br />" <br />pleconciled quantfty- with <br />es <br />181b. Alternate Facility (or Generator) U.S. EPA ID Number <br />L) <br />LL <br />Facility's Phone: <br />18c. Signature ofAltemate Facility (or Generator) <br />Month Day Year <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />(3 LU <br />1. <br />Mug <br />2. <br />I <br />3. <br />4. <br />20. Designated Fac ility Owner or Operator. Cq Mfication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Na, Signature Month Day-.. Year <br />"Ito <br />rr/-% ruriii OIVU-44 IM8V. J -UO) Previous eamons are obsolete. DESIGNATED FACILITY TO GENERATOR <br />