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Please print or type. Fnrm bnnrn-4 r)hAP Nn T)ro-n qO cin runn of uu-« F v. tz-i r ( erevious ennions are obsolete. / DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM UNIFORM HAZARDOUS 1 Generator t[) Number 2. Page I of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST ,, ., , A r 5 0 3 JJ K 5, Generator's Name and Mailing Address Generalor's Site Address (if d4erert than mailing address) Generator's Phone:` 5. Transporter 1 Company Name" t. U.S. EPA ID Number - - 7, Transporter 2 Company Name U.S. EPA ID Number B. Designated Facility Name and Site Add. -.-ss U.S. EPA ID Number saoia CA 9569 Facility's Phone: 01 A 1. 1 _ r,,747 r — 9a. 9b. U.S. DOT Description (tnduding Proper Shipping Name, Hazard Class, ID Number, 1r1. Containers 11, Total 12. Unit' HM and Packing Group (if any))13. Quantity WI.NoI. Waste Codes Na- Type 1r f 40 Ar.. Z 2. Uj 3. i 4. 14. Special Handlirg Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: E hereby declare that the contents of th#s consignment are fully and accu described above by the proper shipping name, and are classified, packaged, marked and fabeledlplacarded, and are in alt respects in proper condition for transport according to applicable intemartion an national governmental regufaltons. If export shipment and I am the Primary Exporter, I certily that the contents cf this consignment conform to be terns of the attached EPA Acknowledgment of C sen I certify that the waste minimizalion statement identified in 40 CFR 262.27(a) (it I am a largo quantity generator) or I a a small quantity generator) is true, GeneratarsiOff roes Printed/Typed Noma Signatur _ r>Ix Mrronth Ra Year � 16. Intemational Shipments ❑ Import to U -S. ❑ Exnort from U. Port of entnlexit. Transporter signature (for exports only): Date leaving U.S.: LU IT Transporter Acknowledgment of Receipt of Materials Transporter 1 Pr tedffyped Name Signa E7 Month Day Year � GYear Z Trainsporler 2"ntedfTyped Name Sig Month Day i— Ia. Discrepancy 16a. Discrepancy Indication Space Ouarttity Type Residue ❑ ❑ ❑ Partial R.�ecfion ❑ Full Rejection cti Manifest Reference Number: 18b. Alternate Faciiity (or Generator) U -S. EPA iD Number a L) tat Facility's Phone: 0 180. Signature of Alternate Facility for Generator) Month Day Year d Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) � 1 2. 3. 20. Designated Facility Owner or Operator: CeRificetion of receipt of hazardous materials covered by the manifest except as nded in item 18a Prinlodflyped Name Signature Month Day Year �� cin runn of uu-« F v. tz-i r ( erevious ennions are obsolete. / DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM