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RECEIVED MAY 06 2014 <br />Pleas& plant or type. (Form designed for use on elite 12 -pitch) typina lac) Form Approved. OMB No. 2050003 <br />UNIFORM HAZARDOUS i Generator ID Nura er 2. Page 1 of 3. Emergencyfiesponse Phone 4. Manifest Tracking Number <br />WASTE MANIFEST ^r�cw Y s 0 0 7 J� <br />? 1! 4J A <br />5, Generator's Name end Mailing Address ' Geneir is SileAddress(rdtlferell than matting address) <br />aAat6 nirpir1is,G(i uy GtDta��.14 Staz�'a ('ice€11£Ctil <br />2302 Lail -An Clark 1410 [ndustrifal ih. <br />Generator's Ph on e; <br />6. Transports I Company Name U.S. EPA ID Numher <br />aprr, Errz{sr+�ttr,?n4c�9 Sir .11�L = ('+d3. TSox?56 West 5z�r::rn.ttr. f'4 9.: e. <br />7. Trensponer2 Company Name :, <br />U.S, EPA ID Number <br />a. Designated Fxllity Name and SRe Address '� <br />-' U.S.:EPA ID Number <br />[tom+lo) 's':a ry�drli <br />64 06 UPY Fr ocd _ <br />Fuel Phone: 707 451 't274+ 17a kaAJ1e5CA 95ryg^ C':41)982��475. <br />gar gb. U.S DOT Description (including Proper Shipping Name, Hazard Cma , ID Number, 10. Containers <br />HM load Packing Group (if any)) IT Tolai 12. Unit 13. Waste Codes <br />1. <br />No. Type Quarl Wt.Nol, <br />t <br />0 NA2.2[i, ASBESTOS.: 911'U[[[. <br />W_ <br />2. 4 I P7 I <br />1 <br />14:5 at Handling Instill sand AddNonallnfecompl r - <br />PA Req ON IX 14AAQNID, 939 EMS Street <br />a FruxteiscL, CA 94109, (415) 77111.6660...kSWSi [tetra>e e1 Rerjjij%f rt,W <br />40CFR6 it 131 11 11,ed, sca[ed.lahelyd . <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the conlenls of this consignment are tally and accumfety described above by the propership1119 name,aM are dassiiled, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable International and nal governmental regulations. If export shipment and l am the Primary <br />Exporter, I certify [hal the contents of this consignment conform to the terms of the allached EPA Acknowledgment of Consent <br />I call [hal the waste min orazaBon statement identified In 40 CFR 262,27(a) (it I am a large quantity generator) or (b) (I I am a small full generator) Is We. <br />Generalor's+0(feror's P6ntedliyped Name' Signature Month Day Year <br />--1 <br />16. International Shipment '. <br />- ❑Import to U.S. ❑Export from U.S. . Pod of emlryfexit <br />Transporter signature (for exports only); Dafe ieaving U.S.; <br />w <br />IT Transporter wledgmenl of Receipt ofMalerials <br />Transporter 1 Ato and ame Signature <br />® F \Ill r Month, D Ylaii®ar P <br />ad <br />2: 1*b y �s /p <br />Tronspoder2 Pdnled7Typed Name Signature <br />Month Day Year <br />screpancy <br />I 18e. Discrepancy lndicahon Space <br />❑ Quantity. ❑ E:1 Residue ❑-, -Rejection ❑Full Rejection <br />Manifest Reference Num <br />18b. Alternate Facility (or Generator) bar: U.S. EPAID Number <br />J <br />till Phone: <br />the, Signature of Alternate Faciii(y (or Generator) <br />Month Day Year <br />ne�n+i Memod [;odes (Lei codes for hazardous waste treatment, <br />disposal, and recycfng systems) ' <br />�-^ 2 9 4' <br />IAL Cerl'Riralloo of receipt of pailiabil matelots covered by the manifest except as riv in Item 111 <br />p <br />?'{ Signature , <br />*fi �` Mo Ih I Da Oy Year <br />P ...r�"'�"a'.�.,.�,.... �s�t`v�x3lPyGr- <br />s editions are obsolete <br />€ IE'.81fANKIl FA(;I€ATV 10 GENERAT® <br />