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lease pr' ortype. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number' 2.Page,1 of 3.Em Response Phone 4.Manifest Tracking Number <br /> UNIFORM OZARDOUS �t4FI..- <br /> ,VVASTEMANIFEST CA1dt��03.�t1r�7► 1 1-X00`499-7145 02035779:8 J�" <br /> Z.Geriersitot's#derue and Mailing Address r Genexatds Site Address(if different than milling address) <br /> E ZAL I .DDR MESA GOI. GTS <br /> 18501 STANFORD-- RD. <br /> TRA,PY CA 97 <br /> Generator's Phone. 9t224-1494 <br /> S.=Tr nsporter 1.Company ame U.S:EPA ID Number <br /> CI FIO R &GURCE -RECOVERY.GERV.ICEG OR3 X52405 <br /> 7.Transporter 2 Company Name U.S.EPA ID'Number <br /> 8.Designated Facility Na_nre and Site Address U.S:EPA ID Number <br /> nCIFIC SOURCE RECOVER` SERVICES CAI?00852405 <br /> 315t ER9T PICA'BL'VD. <br /> L.09 ANGELES, CA SW3 <br /> Facility's Phone: (800) 499-7145 <br /> 8a 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 /> _RAT ,, �r 1 <br /> Lul <br /> Dim <br /> DPI 2- <br /> 4.CLEAN <br /> CLEANING SOLUTION) (CALIFORNIA REGULATEDq <br /> I ,ONLY,) 8di i L3 <br /> 14.Special Handling Instructions and Additional Information <br /> - 9b #-RRA. :b3F 6334 9F4) APO 6339 <br /> L <br /> GLOVES GO G PROTECTIVE CLOTHING 4 R EMERGENCY CONTACT;. 'KIRK W LDORF <br /> TRANSPORTER-1 € ( E . -8813-213-1.3415 II !II! !f �� II t ll! I IIII! III I!I I, II lid 6' <br /> 15. GENERATOR'S/OFFEROR'S CERTIFIOATION: I hereby declare that the contents of this consignment are fully and accurately described above by the ro er shipping name,and are classified,packaged,: <br /> marked and;labeled/ placarded,and are in all respects in proper condition for transport according to applicable international and national governme regula i S.If export shipment and I am the Primary <br /> Exporter,l 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(x)(if tam alarge,quantity generator)of{ti ifl am a quanfity gen ator)is <br /> G erators/0 sp' ted/iype" ame nature Month Day :Year <br /> sf' <br /> 1 . ntern onaI Shipments r <br /> ❑import to U.S. Export from U: Port of entry/exit: <br /> ? Transporter signature(for exports only): IleDate leaving U.S.: <br /> f 17.TransporterAcknowledgment of Receipt of Materials <br /> Ttanspoiter T P.rinted/Typetl Name Signature l Month Day Year <br /> a' � <br /> Transporter 2 Printed/Typed Namecc Signature M n ay ' r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space '.: y <br /> ❑ Quantity ❑Type ❑Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b:Alternate Facility(or Generator) U.S.EPA ID Number „ <br /> r t; <br /> c� <br /> li Eaciljty'sP.hone:-.... __r ..:.._,.. .. a <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z . <br /> 0 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI1. 2 3. 4. <br /> 20.Designated Facility 0 neror Operator:Certification of receipt of,hazardous hazardous materials.covered by the manifest except as noted in Item 18a <br /> Printed Typed Na 'Sign Month Day Y ar <br /> EPA Form 8700.22(Rev.12-17) Previous edi ions are obsolete. , " DESIGNATED fACILITYTO GENERATOR <br />