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Please print or type.(Farm designed for use an elite(12-pitch)typewriter) Farm Approved.0M8 No.2050-0039 UNIFORM HAZARDOUS 1•Generator ID Nwnber 2 Page 1 of '3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CALL 04 �30 t 0167497461 JJ K 'S,Generalats Name and Mailing Addressfz" :� Ix1 -= Generators.Site Address(if different than mailing address) d tr Yi3 ' i }„ ,:j.j 4I�q 1'.1 7;b „ 'tt3l Generator's Phone: 6.Transporter I Company Name U-S-EPA 10 Number 7.Transporter 2 Company Name �,'•- U.S.EPA I D Number 8.Designated Facility Name and Site Address, C dcf r. U-S-EPA la Number 100 W 171h Ea. C.AD0�sl f3i } Long Beach.CA W7j310 QSA Fadiftys Phone: ge• gb.U,S,DOT Description[including Proper Shipping Name,Hazard Class,ID Number, 10.Containm 11,Twl. 12.Unft 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. Cr. 1' f40rN � 2. - 1 3 j 4. S.S�gaal Hand mg t s uCtinn 3,a d Nd4itx�n i lr�r�n Det�rjS O?f P! ' �fe9trry ern rtn ie Ct 13Etr f?+�1 Yatr}r 15. GENERATOWWOFFEROR'S CERTIFICATION: I hereby dec4are that the contents of this consignment are fully and accurately described above by the proper shipping name,and am classified;packaged, marked and labeledfpiacarded,and are in all respects in proper condition for transport according tv applicable intemationaland 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 EPAAcknowledgment of Consent. i certify that the waste minimization statement identified in 40 CFR 2$2.27(a)(if I am a large quantity generator)or(br(f I am a small quantity generator)is true. Generator offerors Printedlryped Name Signature Month Day Year :1 1$,International Shipments ❑import to U.S. ❑Export from U.S. Pert of entiylexiE Transporter signature{for exports only}: Date leaving U.S.: W 17.Transporter AckrorMedgment of Receipt of Materials Transporter 1 PrintedlFyped Name `' Signature Month Day Year MTransporter 2 Printedlryped Name Signature Month Day Year a i8.f7lscrapancy 18a.Dlssrepancy Indication Space ❑ Quantity ❑Type ❑Residue , ❑Partial Reju-Aian ❑Full Rejection Manifest Reference Number: 18b,Alternate.Facifity.(or Generator)` U.S.EPA ID Number Fadtity's Phone: 18c.Signature ofJiJtemMe Facility tar Generator} Montle Day Year 2 '.Hazardous Waste Report Management Method Codes(i.e..codes fat hazardous waste treatment,disposal,and racyding systems) 14. ' 20.Designated Facility Dwner or Operator.Certification of receipt of hazardous materials covered by the manifest except as acted in Item 18a Printedfryped Name Signature �-" Montle Day Year. EPA Form 870042(Rev.3-05) Previous edit ins are obsodefe TFtAN$PO3T R'S COPY �.