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Please pant a type. Form Approved.QNB No,2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Humber <br /> WASTE'MtEANIFEST ;A igjt wio-no �slkt}4 2 ;tits '� <br /> JJK <br /> 5.Generator's Name and Mating Add Generators SiteAddress(8 different than mailing fires) <br /> �IR.) 1.n�vcW zS t "fijsk� 3d7'�fi } Cjt:rr!-1 r.,e W-4'.q fn !t• Ait-1 71 <br /> �y4C!�i�etiH, i1ti .;=a�i� 1.127f� <br /> Generatars Phone: „ :!, y 7 :i <br /> 8,Transporter 1 Company Name U.S.EPA ID Neumt. <br /> •"'.'t;,t,�"sF'r�)1��r���g l""1:T�r ',fiR�!'tRf+Y�•�•1�K - - 41FSP V V u'M-d��L <br /> 7.Transporter 2 Company Name J.S.EPA 10 Number <br /> 8,Designated Facility blame and Site Address L U.S.EPA ID Number <br /> C t't;>sby C�1rIFIft,lhlia- s^�t�r)" i1t i t►f€# <br /> 1630 W. 1 t'tt1 St. <br /> §Bo- <br /> ',-,t ,,tea Lt ndgeech,CA 90781:USA. <br /> Fac fi 's Phone: - <br /> ga. 9b.U.S.-DOT Descript on{ncfudlrhg Proper Shipping Name,Hazard Class,[D Number, 10.Contai iers <br /> 12,Unit 13.Waste Codes <br /> HMand Packing Group[iFarty}} , Qu No. Type QuantitynfityTotal Wt,Nol, <br /> 1. <br /> 2. <br /> W <br /> Ch <br /> 3. <br /> 4. <br /> 44.Special Handling Instructions and Additional Information <br /> )bA.W-1 t-#ef'i,14b'swbel'.t,0,i3 S,tJxXA's [151 1 9 Wear APP"V�91'6+�k)thrng0 Res t47r <br /> 15- GENERATOR`S10FFEROR'S CERTIF1CATFON: I hereby declare that the contents of this consignment are fully and accurately des0dbed above by the proper shipping name,A are liassified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport accdrdibg-rd Nopllcable,khtemationaland national governmental regulations,I1 export shipment and l am the primary <br /> Exporter,l certify Shat a contents of this consignment conform to the terms of the attached EPAAckrrowledgment oftonsent. <br /> I carlify[hat the waste inimization statement identified in 40 CFR 262.2Z(a)of I am a large quantity generator)or(h)(dl im a small quantity generator)is Sue. <br /> rator'slOfferoes 'nt f.Jyped Name $igne�ure. --• y� Month Day Year <br /> In matin l Sh mbnts ❑I td U-S- r� <br /> � "`-----'---r Pchrt of mbykxil: <br /> z Transporter signature(far exports only): Date leaYing U.S.: <br /> W 17.TransporterAcknovdedgment of Receipt of ftedals <br /> nsportar 1 Pnnta fypad e = Signature Month Day Year <br /> ^� <br /> a Transporter 2 Pdrite0yped Name Signature s Month Day Year <br /> 18-Discreparicy <br /> 18a.Discrepancy Indication.Space ❑ cwantity ❑Type ❑Residua ❑Partial Rejection ❑Full Rejection <br /> A.: <br /> Manftst Reference Number. <br /> 18b,Atemate Facility(or Generator) U-S-EPA ID Number <br /> U <br /> Fscilityrs Phone: <br /> 180.Signature of Altemate Facility for Generator) Mongr Day Year <br /> Q <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and reeycting systems) <br /> ,! ! 2. 3. 4. <br /> i <br /> r <br /> 20.Designated Facility Owner or Operator.Off-cation of recell of hazardous materials covered by the manifest except as ri eW in 1t 189 <br /> PfirltsdlTyped Name 1 Signature . tt Day ; <br /> EPA Form 8700- {Re .12.1.7] Previous a Itfvns are n6sn1e TRANSPORTER COP <br />