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qSL V SHIP# -'31010391 1111111111111 �IINlll�llllilln se print or type. 007439901 SKS PleaForm Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Erne en Response Phone 4.Manifest Trackin Number WASTE MANIFESTrnpi 1. '- G'.ItA-4c1} inn SK 5.Generators Name and Mailing Address Generators She Address(it different than mailing address) E s c a I o n ,'rBalier E`r-ands T., 1915 Mrhenry 1)'.a FSCTI!fM CA 9. :?17)- 1'l?>v0 Generators Phone: 20Q =SOF 1 6.Transppooher 1 Company Name PgFFT '-}/1 crN 1=�7-,!.=:MS T )[` U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and one Address 2 21 50 sFZAF-"Y_.Ffi:`-r•1 "yC- .Me :NF, U.S.EPA ID Number ,000 88TH 9T REF'r t ^iG-7�F-t Facility913710 i i's Phone: !'AIT}' 000;{47 1-r 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 0.Containers 11.Total 12.Unit HM and Packing Group(e any)) o. Type Quantity WLNd. 13.Waste Codes NON-RCR I HA7APPOUS WA8TF. l.It7UID nil O tclni11713 rj'- QTc z (,ncs{FR "ilii JTIO"d S 1 oe w w 2. I 4. 14. .pedal Handling Instructions and Additional Mforrnatien TSD SCA r f.470s9 SIZT1114 CS ' 24H EMERGENCY#8 0 ,F.8-1TD91 CI-4 'qK/7F TC , .+ rafiair9d by genera or r_nr{Fr= Tg rr-y a, s.t10 i. y 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare Mat the contents of this consignment are fully and accurately described above b the y proper shipping name,are are classified,Packaged, marked and Iabelehat th conterded,and are in all respects in propercondition the ten for transport attached Eng to applicable em of tion>p and national governmental regulations.If export shipment and I am Me Primary Exporter,I ceNfy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Ooent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(e I am a large quantity generetor)or(b)(if I m a small quantity generator)is true. Gen9raMrs/Ogerors PrintedlTypnd Name Signature Month Day Year 7IJ Ar P RE ,E$' 03 a1 JaG j 16.International Shipments ' F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: K Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Tre sported PrintetlfTyP ame SignaW Month Day Year aw. a3 ^ Z Tr spo r 2 P'ted/Typed Na rid a nature Month Day Year F L arm c � 7? .N 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Rashid. ❑Partial Rejection ❑Full Rejection Manifest ference Number: t8bAter nate Facility(or Generetor) U.S.EPA ID Number J U LL Facility's Phone' F1 8c.Signature ofAltemate Facility(or Generator) Month Da Year a y Z y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling s terns) 1 4. H141 2 3. 1 20.Designated Facility Owner a Operator.Certification of receipt of hazardous materials covered by Me manifest except as noted in Ilam 1 B Print ypedNa Signature ..�l ZO C Monts Dray Y®r EPA Form 4122(Rev.12-17) Previous editions are obsolete. DESIGNATED OULIT O EPA's e•MANIFES SYSTEM.