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. :.,... Form Approved.OMB No.2050-0039 <br /> for use bn et'a 12 itch t writer. <br /> Please;gi(nt�gij Fon designed. .. C< P 7r� Pho�MrllNumber It' <br /> r' ;iiGeneramrdD Ntiif>ber' 2.Page 1 of'3.Emetgency:Respom <br /> :QN-05 ot,s.: CALDt7t�332107 1 800-424-°� 0 7 9 9 4 'JJK <br /> Wq$�Ew1t1ANIFEST.'.z.-. <br /> "``` ' Generatods Site Address(d ditlerenl than mailing address) <br /> Addren <br /> 109985.::FP;;tL•fEN:RIl. <br /> FRENCH,CAb1P: t„fi'95� <br /> - <br /> U.S.EPA ID Number- <br /> lea <br /> ZIP A*, 4•t�?rrr C/IM413252 <br /> Y >�flNii[Lf]TALERVi�ES' <br /> `' U.S.EPA ID-Number <br /> 7:Trti" •r (p >N, Y CAROW1775V- <br /> '=' TRIAL.SERt1ICEs APIC. <br /> .. U.S.EPA lD Number <br /> Si S3itFa _ ,s -: <br /> st. <br /> 'FEEtN[EX;AIU�l <br /> :Fa,'L''r,s�P.h '" � <br /> 9�1U S�DOT+Desarpdo_n:(including Proper Shipping Name,Hazard Clens,ID Number, 10.Containe s 11.Total 1Z Unit 13.Waste Codes <br /> S❑ an�IP Skin'Gmp`(t>?nY�). '.. . No. Typo Quantity WWoI. <br /> HM i0 <br /> ! P <br /> W <br /> J <br /> CD <br /> r r ;3 • <br /> 4 <br /> 41 <br /> a t r f drum size r , r . <br /> 4 - <br /> � -.r.. �. y y.�.�*.�_ •z..x-.t y°y�ht.+ a3:v'"))�F.Si.1Jt.c ri .. .. .. , <br /> ;'",cbf �rirrrQntSla fifl[�ahNraauratety desalt ed aboya bylhe proper shipping name,erd eie claeaJjletl d�9 s <br /> ua f poit.ccoi (rig ta'appl�able'lafema lbnal and national governmental'regulatlons:ifexport shipment and l emtlhe a yry j <br /> d n a u ues ro con tlon bans a <br /> t8 B Re a ��1Ro"jttteifefApffheattached EPAAdrnowledgmentofConsent. <br /> EA of• t 140E( 2822{(6)(IF1'am a large quantity generator)or(b)(it I am a small quantity generator)is true <br /> s .G� tdf�jG97f�i37� d � �� Sign M th Day- 'Year <br /> til ; , I <br /> Y..,{h - <br /> .in faro .Va '0�1� 'I�njg�a ""7>;•��' ) r��•.. - <br /> t r x Impylt V:$ ❑Export fmm U.S- ort of enlrylax>r - <br /> �Tiansporters(gnal (fii,eilports Anly) . <br /> Date leaving U.S.: <br /> ..r r7!Sr�rtsporferAclowwiedgnfeni`ofReceipt•afMelerhls <br /> Transpbrteft'Prnl66Typed! a Signature Mdnth Day, `Year <br /> 1 fTrrineporfer2Pd dl]ypdd!Name Sign rem <br /> is•, - '�" � l"�• <br /> 18. <br /> Cis <br /> aepancy r 1 <br /> 1Bas Discrepancy indication Space Quaatliy Ts po ❑Residue LJ Pardal Rojedlon ❑Full R�Jedlon <br /> _ Manifest Reference Number. <br /> 18b:Allemate Facility(or Generator) U.S.EPA ID Number <br /> a. ..J+d•. .1 <br /> '— <br /> ', Sc SignaturecfAlternate Fadltty(or Generator) 1 <br /> + poral, recycling systems) <br /> '19:Hazardous Waste Report Management Method Caries(i.e.,codas for hazardous waste treatment des and r r <br /> 4- <br /> ':-,_.:20.0esignated Facility Omar or Operator.Certi6rxfion of racerPt of hazardous materials covered try the manifest except as noted in Item 1 Be Montlrt D Sr' x ear <br /> ;r r ° ;t7nted/r N + Signatirre < tA nr <br /> 'YPed,a rr F f'`f"k•'��,�'.r. _ i�" v' 'ts.WEN <br /> •i_I <br /> ` ' F�A�Fo8700 22(Rev 3 05�'previo'us`edfion's•afe obsolete. DESIGNATED'FACILITY70 DESTINATION <br /> rrn STATE( �1 )A <br />