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FomAppraveC.OP,18No.2050.0039 <br /> Please print or type.(Form designed for use on elite(t2-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST :AL0101tb427613775 7WF69 011385922 FLE <br /> 11.Gecerator's Name and Mailing Address Generator's Site Address(if different than mailing address, <br /> B tht 8. 1—".dk, Orti 1:= i51 1-i,t h 8 Ftr-I., td-0i 1,_11151f-` <br /> 1,1)472~9339 4950 PACT F IC AVE. WEBEF."3t04itJ MALL.,' 5 P A C E 4950 PACIFIC AVE <br /> Generator's Phone :13I—O KTON. CA 95,'_0; '3TODJON. CA 9520: <br /> "o-,ransporter 1 Company Name U.S.EPA to Nurbor <br /> �tevICvC1e JOeCIaIty 4)3 t. .[!i,!Llr-r r: 1+11.4-80el0.110-9�, <br /> 7.Tran<_oorter 2 Company Name U.S.EPA to Numoer <br /> War IdFiid- ReCOrer a S=/5ti-�id CAR00017542-1- <br /> 3 Designated Facility Name and Site Address y U M 3 'f e=, i-.j U.S.EPA!D Number <br /> 2 30 E. 13t 'Stt-80L <br /> r'acrd/sPnone. +2'36,428-938 A4RO00515'K+ <br /> e 9b-J.S.DOT Description firc uding Proper Shipping Nara.Hazard Gass,D Nu neer. iG.Ganta mens 11.Tata! 12 Unit 13. IJasta Codes <br /> HFA and Packing Grouo(if any)! Nd Tyae Quantity lil.!al. <br /> 'Nor. RCRA ha23f'dt5r-t5 wa=-t E. 1 tr11.1=G 3 <br /> 0 - <br /> o Latiansi, <br /> a <br /> LU <br /> LU 2 <br /> w <br /> I <br /> 3 <br /> 16 Speciai Hardkr:g instructions and Addifioral Informationilk. L.L a'_t 1 d b) <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that ice contents of this consignment are frilly and accurately described at by the ershippingnallife.and are classified,paaaced, <br /> marked and tabeledlplacarded.aid are in all espects in proper corditio::lo-transport according to apptabie international and national gc.,n-ntat _ !tons-If exoart womem and i am?he?rima. <br /> Exporter,I certify that ice contents of this ccns,q_nment conform to the terms of toe attached EPA.Ackn;*ecoment of Consent. <br /> I rerb6i that the vas'ie mimnvalgn statemant identified in,40 CFR 262-27(a!pf arr a'arge quantity geraratrin ar(b)(if I a. a smaii^,ua-Lary gen 'is:rue. <br /> Gere for e ted s Panypetl Name gna;ure_)RCL. c v Cry f1 1Y ( v F C I ill t t e Month ay ear <br /> tr I I'it ilia 19 <br /> J ic.iffemauonaf Ship- is <br /> �• 71 mport to U.S _J Export from po„U.S. of entrylex.!: <br /> Z Tans rter si nature t,orexporL rI 4 Da 81".1 <br /> tx i%Tramsaater AeknGvtedgment of Receipt of Materials <br /> UJ <br /> K Transporter 1 Prmt?0? -Fed Name ign re - oath ar <br /> ay e <br /> a At-ithorfi` frid�.t-. I i _ 10 p1`3 <br /> Z Transporter 2 Prnted,Typed Name °:tenth ay Year <br /> ,L o I <br /> !8.Discrepancy - t <br /> 13a Disuerrancy Indication Space Quantity Type ❑Residue ElParia!Rejection !Full Reiection <br /> q Manifest Refarerce Number <br /> F 1'_0 terna'r:Fadi<tj icr G?reratar} ;S.EPAID Number <br /> J <br /> U <br /> Q <br /> LL =acikc's Phore. <br /> W tEc..Signa+;;re of=.ter^ate Fa:flity fcr Ge.^.eralor Ld�rth Day Year <br /> Q <br /> Z <br /> 19-Hazardous Waste Repti-I Management Metrod Codes te..codes for razardous wastetreatment disposal.and reacting systems! <br /> O t 2 3. 4, <br /> 1 <br /> 2.DeAra!ed Facility Osne'or Operator Ceo frcation.of receipt of riazardeus mateda-s covered by the mari': _r except as.^eied X.item 18a <br /> PnNed'TypeIt-Wil -tiA <br /> Sf-st e Month Day Yea <br /> ol I <br /> vq1 ! <br /> EPA=arm 8700-22(Rev. -05) Previous editions are obsolete. !-,31 hJ f�-G FACILITY TO DESTIMATION STATE(IF REQUIRED) <br />