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Pease prim or.type.(Form desagrled for use on elite(I2-pitch)typewriter.) Form Approved.GMB No.2950-0039 TUNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Fme G Res ossa Phone b.WaniFest Tracking Number vl's Name and Mailing Address Ft)3 ;ramel# Generators�IteAddress,ilf different than mli pgtaddress) w `7fjFi 5 lY ls� �;r•., . .Y,,.1,: ;:,:_- ., Fi ktpEl�3 !hl r`.�iiYl3 :a�4 '14$ €S(A R4$. Generator's Phone: B.Transportar 1 Company Name U.S.EPA ID Number !',Aprj0" {:0fewr1.:fr�;�.,;';y.Tdms wet e5 kg:. 7.Transporter 2 Company name U-S,EPA IO Number &Designated Faetlity Name and Site Address Mennno p U.S.EPA Ill Number 2130K)KoMf ilamcki - �;A Touqoo- '#`may t: Wori CA S0122Z 27-49 U-SA Fadrdy's Phone: 98. Rb-U,5-DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12-Unit HM and Paddng Group(it any)) 13.Wasre Codes No. Type Quantity L'ytJVol. PG tI LRG&1 1214 �.. ..... W E i 4- i. - 1.Special Handling.lnstructfons and Addition al Information 15. GENERATOR'SIOFPEROR'S CERTIFICATION: I hereby dedare that the contends of this consignment are fully and amuralely described stove by the proper shipping name,and are classified,packaged, marked and labefedlplacarded,and are in all respects in proper condifian for transport accord Ing to applicable international and nallonat governmental regulations.If export shipmem and I am the Primary Exporter,I certify Itrat the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Cense I certify that the waste minimization statement identified in Q CFR 252.27(a)(If 1 am a large quantity generator)or(b)(If I am a small quantify generator)is true. Generators[Offerors PrintsdfTyped Name Signature Month- . Day Year 38.infematicnal Shipments- ❑ F Import to U.S. ❑Export from U.S. Port of entry1mt: M Transporter signature(fur worts only): Data leaving U.S.: LCe 17,Transporter Acknowledgment of Receipt of Materials a� Transporter 1 Printedff'yped Name Signature Month Day Year Transporter 2 PdntedlTyped Name Signature Month Day Year � f 18.Diwapancy 18a.Discrepancy.Indication Space Quantity ❑Type ❑Residue ❑Partial Redion e i ❑Full Rejection Manifest Reference Number: 18b,Aftemate Facllfty(or Generalor) U-S-EPA ID Number r U L Fadilly's.Phone: W I&-Signature of AAemata Facility(or Generator) Morr[h Day Year F r� ..Hazardous Waste Report Mana eP gamenf Method Codes(i,e-,Bodes for hazardous waste treatment,disposal,and recycling systems) t 2. 3- A. 20.Designated Faeflily Owner or Operator-Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrntedTTypedNqrpe Signature nth Day Year EPA Form 6700.22(Rev.H$)) Previous editfans are obsolete. *�, TRANSPORTER'S CORY