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Please print or type. Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number e 2• Page 1.of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST � ' t 0 6 3 1 ' 5 0 7 1 ael�a�24MB � ^q 1. 3 4 3 6 0 JJ K 5: Generators Name and Mailing Address Generator's Site Address (if different than mailing address) ILS ftm SW 01 Px4ft US - clo GM 10*X* lJ8 �C'olpoll�le 1*0 Xiia„p h"y N�011111 N N 4iZ78 ftCk ae CA 90 Generator's Phone: S 4 a - 4 7 $ 0 6, Transporter 1 Company Name D! U.S. EPA ID Number ,ad SalrvJW% Into. 0 A R 0 0 0 1 4 8 3 38 7. Transporter 2 Company Name JUL U.S. EPA ID Number 8, Designated Facility Name and Site Address GHp U.S. EPA ID Number WM Indianapolis Cmwbn CA SM Facility's Phone: 310 a W710D ICA T 0 8 0 0 1 3 3 5 2 9a, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit HIM and Packing Group (d any)) 13. Waste Codes No. Type - Quantity Wt.Nol. ® . . * IIIA" YrVOMM fM9rRR Gasobw cav PVA! iJO I U018 F— / 9 L ., L TT I Z 2. LU 3. I 4 . I � 14. Special Handling Instructions and Additional Information U11111444 ;; Weighto vr ' wh i.1341to ApproX mate- '1S Jcab# 8.1007 " 001 -2 R10t# t: 004407 q 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable. international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgm Yof Consent. I certify that the waste minimization st identified in 40 CFR 262.27(a) (if I am a large quantity generat f) or ( (if I a sma quant' nerator) is it e. Gertp /Offeror's Printedrryp//ed Name Signature l Month Day /Year 1 . Intemationa Shipments F ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: Z Transporter signature (for exports only): Date leaving U.S. : Ce W 17. Transporter Acknowledgment of Receipt of Materials 0 Transporter 1 Printed/Typed Name Signature Mo Day Year CCS AR( 06f � L i Transporter 2 Printed/Typed Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ O uanti ty ❑ Type ❑ YP Residue ❑ Partial Rejection El Full Rejection �I Manifest Reference Number: 18b. Alternate Facility (or Generator) U .S. EPA ID Number J C.V LL Facility's Phone: W18c. Signature of Alternate Facility (or Generator) F Month Day Year i19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal , and recycling systems) p 1 2, 3. 4, 20, Designated Facililty 0 ner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedlryp4Na Signa Month Day Year mv) h� JS EPA Form 870 . 12-17) Previous editions "are obsolete. DESIGNATED FACILITYTO GENERATOR