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Ill aAntoiril a. l danlnnnrl lnr ima nn alga W).nitr.l tv(wvurftar 1 <br />•V as <br />Form Aproved. DMB No. 2()550.0089 <br />- ^, Nun urw,u bleu ;3-1 I�revlous aditions afe obstJlete. DESIGNATED FACILITY TO GENERATOR <br />:011"ll kWRDOU3 <br />1. Generator ID Number <br />2, Pape 1 of3,'EmalgencyReall Phone <br />I. Menlreat TraclO Number <br />O p 6 84864 FLE <br />WASTE ItQANII EST <br />,r <br />, <br />811100 lune and miallIng dress enefat0 a 811aAddril dirarertitan mailingmddrel <br />41 <br />stockuma CA OM <br />Generators BAohb: <br />Transporter . company riams U.. EPA ID Number <br />AdywrAd Momicia TampW hic. (SV) CAROMM540 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8: 0e4l Facility Name and SiteAddress U,S. EPA ID'Nurnber <br />+� wh ova <br />AftQU"*w NM 87107 <br />:FacliVs Phone: <br />ga, <br />Bb: U.S. DOT Description (including Proper Shipping Nema,Hazerd Gess, 10 Number, <br />' <br />10. Contelnere <br />11. Totet,. <br />12 Unit <br />1S. Waste Codas <br />No. <br />Typo <br />HIR . <br />and Pal Group lif arl <br />Quantlpr. <br />WtlUd. <br />lfW7wi1w wave SS' w <br />OW <br />� <br />P <br />PF <br />IT ac Handling lnettuctfanSant Additional Information <br />l Nil 4W2 OWA"vW it <br />OP <br />11 d Uk 002 li-P)S <br />7 Alur %V'� <br />.ib.. GENERATDR SJOEFEROR'S CERTIFICATION. I herely declare brat the contents of le consignment are fuWand accurately described above by the proper shipping name, and are classified, packaged, <br />marked Andiabeledyplacarded, and are In all respects in proper condition forlranspert accordfng to. applicable International and natural goaermenlal regulations. If export shgtmeud anc I am the Primary <br />Exporter, l cal thatiha ceMenla of this oansignmerd ocnfonn to the teams of the attschod EPAkknowledgment of Consent. <br />I call thatihe waste mioimitation statement identified in 40 CFR 262,27(a) (ff i am a large quantity genal or (b) (M I a small quantity generator) Is true. <br />7 B 10 oPdnbA7ypsd IN a Urs aYe <br />stem B 1prnenta -•, <br />❑ Import to l ❑ Evort INC ln of n;1-41: <br />'Tres ad of rature(for exoorlsOn :' feleavn U.S.: _ <br />W <br />17.TralspoderAdrnnwfsdgmentafRacalptofMalarlsla <br />rana orter a ypad Name na <br />r <br />Lil <br />jTwsponef2 <br />vog vi <br />,-.,. <br />Q <br />., nledfTypedName %-.j Writln Uay nab <br />18. 1019clspency <br />f <br />166. Discrepan0lndlpatbn5pece El quantlty C-'TypD ❑Reski.0 ❑PartalRaj dbn ❑Ill Rejection <br />Mantast Reference Number: - I " <br />18b: A�neta Facility (arQeneratotj U.S. EPA ID Number <br />Fedli s Ifo ' <br />18c. Slgnalure offtmate Il or rjerwal . ay Year <br />Q <br />.19. Hazardous Waste Repot1Marmpernank McthodCodes (I,il codes for hazardous wall traetmenr, disposal, and recycling systems) <br />\y. <br />�, <br />•2t}: Qeslgnated Fectllty Owner or Operator Certification of receipt df hazardous mislerials covered by Bre mardfest yxcepi as nl 1 Ba <br />PrfntadlrypedName Signature Daay7 Yes <br />�iMonth <br />- ^, Nun urw,u bleu ;3-1 I�revlous aditions afe obstJlete. DESIGNATED FACILITY TO GENERATOR <br />