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Amil <br /> Please nt or type.(Form designed for use on elite(12 pitch)typewriter.) - ....... <br /> 1.Generator ID Number Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST -ISI 42 _ '••r 77,E 011385 FLE <br /> 5.Genertetor S Name and Mai ingAddress eneralor'S Site Address p different thanr mailing address) <br /> Bath 8 Badu lJoi-I t 1`iita Fath I Bt -, Wi:t F #i5] • <br /> �I�`�f}r�g339 49.5+0 PACIFIC AVE, WEBERSTOVIN M L_L/ SPACE 4950 PACIFIC AVE' <br /> Generator's Phone: <br /> 0. rans er pany ams95207 <br /> U.S.EPA ID Numum <br /> 6c t t, c: , <br /> 7.Transport.,2 Company Name t -t i <br /> U.S.EPA 16 Number <br /> 41Dr'idalide Recovery SvsteMK CAR0001754cc <br /> B. es gnated acikty Name and SiTe A ress <br /> YU1na YC..c, L_! T U.S.EPA ID Number <br /> Yuma. A2 815365 <br /> Fapli s Phone: 9286428938 <br /> .� .�i1.� 'o f} <br /> go. 9b.U.S.DOT Description.{induding Proper Shipping Name,Hazard Class ID Number, 10.�ContajnersHM and Pack ng Group(if any)) 11 Total 12 Uniti3.Waste Cedes <br /> NoType Quantity WINar. <br /> 1Non RC RA hBZardr,U5 t•13=t e, 1T+1uid iF.cI�I• •. DF t?It3:3c:1 fr <br /> Eotionz), <br /> 2. <br /> 3. <br /> 4, <br /> 4.Special Han cling Instructions and AddiBonal informalion <br /> ! . ( 10,902'St-it e pc+ gttl.at?d i_1.<7r"Iid_1 <br /> 15, GENERATOR'SIOFFEROR'SCERTIFICATION: Thereby declare That the contents of This consignment are fully and accurately described above by the shipping name,and are classified,packaged. <br /> marked and labeled]pleoorded,and are in all respects in proper condition For transport according to applicable internaeonai and national gover ental r tabens.If export sh <br /> Exporter,rcedify that the contents of this ccnsi nmenl conform to the terms of the attached EPAAckrowledymen:of sent prnent and I am the Primary <br /> I certify that the waste minimization statement identified in 40 CFR 282.27(a(81 am a large quantity generarorj or I ;if m a small , f <br /> e or s fro s r yped ame gna•ure Q gener r)is true <br /> � Vq,A�r !. r e f b e 1 f o f I_i N i C e on ay ear <br /> Wmw--, ✓ 12 111G ='411 B <br /> Transporter mg-mm for <br /> LJ Import to U.S. ❑Export from U.S Port of en exit <br /> ex s om <br /> 17.TransportarAC1MWedgment of Rama of Materials Date le i U.S <br /> � rang er ted yps ame <br /> Anthony Mack ur o.th Day eaz <br /> ransporter 2 t yped Name DA k r 1 L 08 ,, <br /> rgna urs <br /> on ay Year <br /> 18 Discrepancy 3 /� <br /> 18a.Discrepancy Indka6ri Space <br /> ❑ Quantity ❑Type Residue❑ <br /> ❑Panial Rejection ❑Full Rejection <br /> f <br /> 18b.Ah mate Fadgry!e Generale) Manrfest Reference Number: <br /> U.S.EPA ID Number <br /> Q - <br /> � F s Pftarre: <br /> W i8c. lure emote atdtry(or naratora <br /> Z Monet Day year <br /> 79.Hazardous Wash RepomMArioqemqnt Method Codes(i.e..codes1. for hazardous waste treatment,disposal,and recycling systems) <br /> rLl ( 2. <br /> 3. 4. <br /> 20.Designated Foci*Owner or Operator.CeA&_tlon or race pt of hazardous ntaledels <br /> covered by the mardest except as noted In Ito <br /> aahae <br /> on ay ear <br /> EPA form 8 00- (Rev. Previou editions are solete. <br /> SIGN Tf- FACILITY TO DESTINATION STATE(IF REQUIRED) <br />