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Please print or type. (Form designed for use on elite (12-pitch)typewriter, Form Approved.OMB No. 2050-0039 4 GENERATOR > I UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number CA L.- 000 LI 0 5 10C, 2. Page 1 of 3. Emergency Response Phone goo .62-cf•q136 4. 14-WI est Tracking Number 015482196 JJK 5 Generator's Name and Mailing Address /3 _1 -I IS eVIcof At•V C. / Generators Site Address (if different than mailing address) Reap( 712o SWivior\Avik 5 4_ lci 6/ S 6. pscowief-0 Av.e.... 81 av H 7-0,11-Fer i , ok or-i 0 G2 Tr-1 CA • at 3 0 ,4 Generators Kapp. g g - ciao - gel& cl, Transporter 1 Company Name U.S. EPA ID Number 3 0--tr t 0 -I- cAt, 1 (19 A ev.e.-srhal ,<ervvets I C°n'c'S'i 8 GC' -Ng Transp er 2 Co y 12... Aepti„). miiel."1„) U.S._W" ID Number V I CIA zeee ''c- Designated Facility Name Site Address cy-0 5- y f exicc+c) /1 U.S. EPA ID Number 1630 Vi • 11th s+ ye At ae"e,fr. , c_Ac ow g i 3 CA Do 7 8'-lo qa I of Facility's Phone: S ° ° % 2 7 67 2-41 ga. 9b. U.S. DOT Description (inclucfing Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit tim and Packing Group (if any)) No. Type Quantity WtNol. 13. Waste Codes 1. NW N le CPA- H•v?........gel,s vv ,,s4---,e.. soli a( Cati/fria it zed otaaf et olith rtesj o 0 I r) F go p t 8 I I ' /VON ,e0e/I (04'4 MAZGrie)---< ,-(0,-5-/-e ..‘cii, d althfces ) 00 OF i 331 , . , . 14. Special Handling tion Instructions and Additional Information propel ,PPE • /as :..2-3 i.)-2._ 3 49 oq s4:p o 8 - 2 I - °04. ?-5--- 15. GENERATOR'S/OFFEROR'S CERTIFICATION: thereby 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I are a small quantity generator) is true. iri Generators/Offerors Printed/Typed Nam Signature Month Day Year ..--- X' ,_4(.0.-4- 11.a-c c ,i I- g- 16. International Shitfirnents port to U.S. Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date lea IX I-. ... (1) Z a 17. Transporter Acknowledgment of Receipt of Materials mp .' 1.1J Tra. 1 PrintedlTvoMName / . / Sig ure Month D Year ' 7 z.../ ,..„ K2- . .. Printed/Typed Narnqe. Signature Monyi Day Year s./17/l9' 1,4fie ...00.kalallIedi , PC9+4 4--- DESIGNATED FACILITY --0- 18. Discrepancy 4. Discrepancy Indication Space LI Quantity type Residue Partial Rejection LI Full Rejection Manifest Reference Number Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I Signature of Alternate Faddy (or Generator) Month Day Year 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. ) ( 1 2. H \ 0 \ 3. 4. 20. Designated Facility Owne or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 Printed/Trd Name Signature (c-k- (----orde I Month Day, veil. Orm 00-22 Rev. 3-05) Previous editions are obsolete. DESIGNATEDFACILITY TO DESTINATION STATE (IF REQUIRED