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2014 <br />Please print or type. (Form desitned for use on elite (12 -pitch) Ivoewritehl Ir``t R P„rm! Annr^,,,,n hsro <br />DESIGNATED FACILITY TO <br />UNIRORM HAZARDOUS I. Generator ID Number 2. Page i o/ 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST C.AL00022160.1 1 X&428.y73� n P� 4A rY <br />g <br />JJ <br />S. Generalofs Name and Mailing Address 1 Generators Site Address Of different than mailing address) .. <br />r<t a �'aaflt ,1 e4Gi? Ct` )5 E �. �1gel�,'. ``,..II a 1.�3/ y {eJ •. <br />! pr <br />I(0 li <br />_ <br />Generators Phone: t DNTka 10'JR1 4t 77,E-'458 (5g,8`g )SILV ,.!imi, d.° AV206 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />V143Iid rdt4Frourferli(d & ri;1E'fzt'&' r (,i. 14ax :--57, VcIea Saw I8�j116?Ito (-A 9.56511 GA,t2(wxit:.b7; m <br />7. Transporter 2Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Stle Adtlress.__._.__...._. __ .. .. ... ...._.___.-_..._.. ..-. U.S. EPA ID Number <br />(tV '.rise;5; �i,•::t; <br />�!'M's KNY Vcro d <br />Faclll sPhona: 7U 4511377tr /l1Trlt@9;.,dH9e,`k? CHi7M0424is <br />gg <br />9b, U.S. DOT Descriplion.(inclUding Proper Shipping Name, Hazard Class, In Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group Ofany)) <br />Quantity <br />W(7Vol. <br />13. Waste <br />Codes <br />No. <br />Type <br />�F° <br />it.., NA2t s, �aSEt.GSPCIS. 9, l�Cv14t <br />3L4A <br />a �i..• <br />�.._� �.._. <br />2 <br />4 <br />14. Special Handling Insimclions andAddiponel Information <br />EPA Region ia; BAAQIVIJ 939 )itis Sired <br />Sasr Pr uloisco, CA 441(19, (4Y 5} 771-tyCv(1..Asb sra,g i�emrn'nl Regrraretwrit <br />aar°rx.�i, �a RGItCi%, xRt�s��>. <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION; l hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledlpimund ed, and are In all respects in proper condbon for banspod according to applicable International and national governments) regulations. If expand shipment and I am <br />the Primary <br />Exporter, I codify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that 0e waste minimization statement denfified In 40 CFR 262.27(a) (if l am a large quangty generator) or (b) Of I am a small quantity generator) fs W e. <br />Generator'slOfferors Pdntedlryp dme Slgnall] d f. Mpn <br />Day Y ar <br />-.� <br />rM <br />16. lemaUonei shipments <br />❑ �• <br />ttc U.S. ❑Expprrtf'am U.& Pmt ofentrylex: <br />Tansporlersigr re (for exports only): '•- Dale foreleg U.S.: <br />on <br />17. Transpoder-Acknowledgment of Receipt of Materials _ <br />Transpoderl pont ypedN e( g ` Signable Month <br />Dayb <br />VL <br />I q6q <br />tYear <br />Transporter PdnietlRypetl Name Sigaalure - Month <br />'Day Year <br />.p <br />16 Discrepancy <br />Inc.Discrepancy Indication Space quantity ❑Type ❑Residue ❑ Partial Rejectfoh ❑Full Rejecllon <br />—.._.....____... .._ __- .. _-_ <br />..- ._ <br />>n <br />._.. <br />Manifest Reference Number: <br />186. <br />Alternate Facility (or Geneaior) <br />U,S. EPA ID Number <br />J <br />U <br />Q <br />Facility's Phone: <br />w <br />tire. <br />Signature of Alternate Facility (or Geneaior) - <br />Month <br />Day Year <br />C <br />Z <br />19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />•!� <br />2 <br />3. <br />4. <br />f Fp <br />20. <br />Designated Faciilry Owner or Operator, Codification of receipt of hazardous materials covered by the manifest except as noted in Item It <br />r, <br />PrinledRyped <br />Neme,, .: /,/ Signature �.�' A Month <br />Day Year <br />v. „tea <br />. ... . <br />f, <br />¢inn nn <br />GENERATOR <br />