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Please print or We. Form Approved.DMB No.205"039 <br /> �:MPC RIV HAZARDOUS 1.Generator iD Number 2,Page I of 3.Emergerxy Response Phone 7021980-969 <br /> nifest Tracklrrg Number <br /> WASTE MANIFEST C A L C C C 3 9 a 0 088-SAI-39401 JJ K <br /> 5.C--neralor's Name and Malting Address Generators 816 Address(if different than"INN address) <br /> C-4, i17rd S1Friply Co CYch8rd Supply 011,i7o <br /> IMM 3 M 9�l51� 2650 N Kaca tt�ur Crr <br /> TreCyf CA 955276 <br /> Generators Phone: 4 cr <br /> fi.Transporter 1 Company Name U.5.EPA ID Number <br /> L:nVtr0nm&n!a I Logi xtius, Inc, C A R J C C 2 1 7 Y 3 <br /> 7.Transportof 2 Company Name U.S.EPA ID NLinber <br /> 8.Designated Fadltiy Name 2nd Site Addro:s U.S.EPA ID Number <br /> t4ad11T3a't TSIX Inc. <br /> 180 W-Monte AwiTius <br /> Bloominpri CA 9T316 <br /> FaaGty's Phone: y f: a r t <br /> 9a. 9b.U.S.DDT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group{darty}) 13.Waste Codes <br /> No. Type Quantity Wt,Nal. <br /> COMbUst hie!Iliald.n.oz.,�I,Mter),PGIII ! 3►k3 <br /> c I -P X00 <br /> 2 <br /> 3 <br /> 4. <br /> 14,Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATION:I hereby declare that the oontsnts of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are In all respects In proper condition far transport according to applicable intematlonaland natlonN govemmenhal regulations.R export shipment and I am the Primary <br /> Exporter,I certify that the oorrtents of this consignment conform to the terms of the attached FPAAcknowledgment of Consent. <br /> I certify that the warts minimization statement ldenfified in 40 CFR 28227(a)(if I am a large quanfily generator)or(b)(if]am a smao quantity enerator}fs true. <br /> Generator'slOReror's PsinledfT ame S gnatum mommh Day Year <br /> -7 <br />,r 16.Imernatrcvtaf 5h r <br /> F ❑Impoit to U.S. ❑Export From U.S. Port of entrylexit: <br /> 1' Transporter signature{for exports only): Dale leaving U 5,: <br /> W 17,Transporter Acknowledgment of Receipt of Materials <br /> Uj <br /> t radspo ter 1 Printod7Typed Name sign / Motilh Diiy ye5r <br /> d ' <br /> 7 <br /> Z Transp ter 2 rintedrTy Name <br /> d ` 5ignafure hi Gaff Year{ <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ c]uantity ❑Type Residue <br /> ❑Partial Nedion l Furl Rejection <br /> 18b.Alternans Facility <br /> Reference Number:ty(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> FactllVs Phone: <br /> Lai 18c,Signature Of Altemate Facility(or Generator; Month Day Year <br /> 4 <br /> y19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> W <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator;Gerkfcation of recelpt of hazardous materials covered by the manliest except as nded in Item 18a <br /> Pnnted/7yped Name Signature Tftth Jay Year <br />:PA Form 8700-22(Rev,12-17) Previous editlons are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />