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Form Approved.OMB No.2050.0039 <br /> ;bOUS 1,GeneratorND Number •'"'` 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> PRfVJiF,EST ii� <br /> Mame and Mailing Address. Generators Site Address(if different than mailing address) <br /> A-1S%IFF JSA,RADESA GOLDEN GTE <br /> ,rACY, CA 9E , <br /> erators Phone: —. 1494 <br /> Transporter Company Name U.S.EPA ID Number <br /> PACIFIC RE pURCE RECOVERY. SERVICES GADO@82E 406 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility,Name and Site Address U.S.'EPAIDNu`niber, <br /> PACIFIC RESOURCE RECOVERY SERVICES CA0008262406 <br /> 31550 EAST PICO BLVD. <br /> LOS .ANGELES, 'CA 90023 <br /> Facility's Phone: 800 499-7146' <br /> 9a: 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit' 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> O o <br /> z X2�JN12f53, WASTE PA RELATED MATERIAL; 3, 0001 ;008 1,005 <br /> PGII, RQ,. (D001 <br /> DM G 214 <br /> 3NON,RCRA HAZARDOUS WASTE LIQUID (WAT'ERQORNE 133 _ <br /> CLEANING SOLUTION) (CALIFORNIA REGULATED 0�i �`�✓ G <br /> ONLY) <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 9W ,6328.03) AP 6339 <br /> CI.C�VES, GOGGLE5 & PROTECTIVE CLOTHINCa 24HR EMiERCENCY CONTACTg KIRK "WALDORF <br /> ���� ��� ���) NONE •.; 1� 11� it 1�lel i �lllli 1�11l11lI1111! !111!1.... <br /> TRANSPORTER 1 PI-tONE 1-�81�8�213�134 __ 4 <br /> 16. GENERATOR'SIOFFEROR'SCERTIFICATION: (hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,arra are classified,packaged, <br /> marked and labeledlplacarded,and'are in all respects inproper condition for transportaccording to applicable intemationalarrdmatibnalgovemmental regulations.If export shipment and i am the Primary <br /> Exporter,I certify hat the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I cern that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or W(dam a small quantity generator)is true..': <br /> ner rS10 es PrintedfTyped Name net Month Day .Year <br /> 16.International Shipments <br /> ❑import to U.S. ❑Export from U.S: Po of ntrylexit: <br /> Z Transporter signature(for exports only): Date avingU.S.: <br /> 17.Transporter AcknoWedgment of Receipt of Materials <br /> Transporter 1 PrinteNTyped Name ! Signature Month Day Year <br /> a Oa2�' '191 <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> jr 3 <br /> 18a.Discrepancy Indication Space ty El Type ❑Partial Rejection Rejection <br /> ❑ Quantity El 1 ❑Fuii <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID'Number 0' <br /> < Facility's Phone: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a ' <br /> z , <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) " <br /> G1 2. 3.' 4. <br /> 20.Designated Facility Ownerror Operator:Certification of r ceipt of hazardous materials covered by th'e'manifest except as noted in Item 185 <br /> PrintedlTyp Na a,, ,; Signature !i ' ; Month Day Year <br /> EPA Form 87100-22(Rev. -17) Previoug editions are obsolete. DIBNATED FACILITY T 'GENERATOR <br /> l <br /> r <br />