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r <br /> Please print or type.(Fenn designed for use on elite(12-pitch)typewriter.) Fon Approved.OMB No.2050-0039 <br /> UNIFORM 1tOkbic S 1.Generator ID Number 2.Page 1 of 3.Emargency Response Phone 4.Mari Tracking Number <br /> WASTE MANIFEST c A D 9 B 2 3 S 6 9 a 1 1 800 a2 10059212 <br /> 29 JJ K <br /> 5.Ge emi Name and Mating Address rwator's Sae Add.IB ddferenithan mating address) <br /> NMMCRANE WORKS <br /> PO 80X 999 . 2373 MARIPOSA ROAD <br /> LA PORTE TX 77572 STOCKTON CA 96206 <br /> Gaterztars Phone: <br /> 8.Transporter 1 Company Name U.S.EPA ID Number f' <br /> I _ U. A1N <br /> 77Number I <br /> e.Desgnatad Fadlity Name and SiteAddreas U.S.EPA ID Number <br /> SIEMENS WATER TECHNOLOGIES CORP. <br /> 53T5 SOUTH BOYLE AVENUE _ C A--D-O 9 7__0 3 -31-1 <br /> LOS ANGELES CA 90D58 <br /> Fadk 16 PMne: <br /> ger, 9b.U.S.DOT Der pBun(Inducing Proper Shipping Name,Hand Claude,ID Number, 1o.cominers 11.Total 12.Una 13 Waste Codes <br /> HM and Parking Group(ff")) No, Type Quantity WLNd. <br /> 1. <br /> NON-RCRA HAZARDOUS WASTE,SOLID(ULY SOLIDS) aOGj <br /> 2. <br /> w <br /> 3. <br /> i <br /> ( <br /> 1/.Special NandOtg InsWdorui and Additional Inbrmaaon pp <br /> L, <br /> NAERG#981 : 171 'PROFILE#981 '.AA181159 OILY SOLIDS,ABSORBENT, SWEEPPO#A110111791 •APPROPRIATE <br /> PERSONAL PROTECTIVE EQUIPMENT 0,5�''— ,-G 6 <br /> 15. GENERATOR'SWFEROIrS CERTIFICATION:I hereby declare that the contents of this consignment are hilly and aceuataty described above by the Proper shipping name,and are dassifled,Packaged, <br /> marked arid lmeadd eacorded,and are On all respects In propn condition for transport according to applicable International and naderuil governmental regulegons.N expod sHpma t and l am the Pdi <br /> ExpoAn,I certify fruit the sntents of this consignment conform to the term of the attached EPAArknowledgmenl of Consent <br /> I cadiry that the waste minimtmgon statement Ideni in 4o CFR 28221(e)(if I am a large quantity generri or a was amity grnnatofj is utas. <br /> GwersioNOgemfs Printed7ryped Name &"to Monti Day Year <br /> !�L <br /> J 1&Imemational Shipments ❑Import to U.S. LJ Evert how,U.S. Pod enW/edf. <br /> tThensporter signature(for exports only): Dale leaving U 5: <br /> C 17.TrwapartnArknmNedgmem of Redact of Mateials <br /> Transported Pnnec1T me Slgrahrte Monty Day Yen <br /> xa / Month Day Year <br /> TampoNer 2 Rinled/Iyped Name Sig <br /> 18.Dleereparwy <br /> 18a.Discrepancy lndl0i Space ❑ Ouanaty ❑Type ❑Residue ❑Partial Rejection ❑Fur Pali <br /> Manifest Reference Number. <br /> 18b.Atten ate Faci§ty(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fecllttys Phone: <br /> aW 18a.SlgnetureofA]teVis Fadlily or Genereler) Monty Day Year <br /> Y <br /> 19.Hazardous Waste Report Management Method Codes(l.a.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2 3. 4. <br /> 1 20.Desigmiad FadltyOw or Operabr..0 mUonotmmptofhaxerdous tadoa ve the mangestexcept as noted In Item its <br /> Prim yped Name Signature Month ay Year <br /> EPA Form 87OD-22(Rev.3-05) Previ It ns areobsbiete. DESIGNATED FACILITY TO ESTINATION STATE(IF REQUI ED) <br />