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Please printer type.(Form designed for use on elite(12-pitc1h)'typewriter) - Form Approved.OMB No.2060-0039 <br /> UNIFORMHMRDOUS 1.GeneratorlD Number - 2.Pag iv 3.Emergency Response Phone 4.111NO tTaeldng NuMlar <br /> WASTE MANIFEST C A L 0 0 0 3 7 6 8 0 6 T 877)818-0087 000780.266. VES <br /> 5.Generators Name and Malting Address; Generators SbAddreos(Id'dferent than mailing address) <br /> FWP INDUSTRIES INC. PWP INDUSTRIES INC <br /> r .' <br /> DBA PACTISILLC DBAPACTIVLLC <br /> 4545 QANTAS LANE 1110 PERFORMANCE DR <br /> GeneatorsPhone:$U9 43-6`014 ST(C_Tera CA ySZnf STOCKTON,CA 95.206 <br /> 6.Transporter l Company Name U.S.EPA D Number <br /> 1IEOLIA ES TECHNICAL SOLUTIONS 14 i D 0 8 A 6 3 '1 3 6 9 <br /> 7.Transporter 2Cempamy Nama .U.S.EPAIDNumber <br /> /vxP�btYUZM ,. l Se 3ll�CvS - 1 . ._ <br /> 8.Designated Facility Name and Site Address - 9.5:EPA DNumbar <br /> VEOLLA ES TECHNICAL SOLUTIONS- <br /> L.L.C. <br /> 17041W. FIRST STREET <br /> FadliysPhene: 616 114-1017AZUSA>,CA 91701 C A D 0. 0 8 3 0 1 9 0 3 <br /> 9a. - 9b.U.S.DOT Deso"on(Inducing Proper Shipping Name,Iizzaid Clews,ID Number, 10.Contaitars 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Gmup(Bany)) No. Type Ouerdy, WCNol. <br /> 0 1. N014-RCPAHAZARDOUS WASTE.LIQUID,(R4K, 491 <br /> WATER-BASED) 8 D M 3 5 13 P <br /> 2. NON-ACRD HAZARDOUS WASTE SOLID (INK SOLIDS) 351 <br /> 8 DM 1409 P <br /> 3 <br /> 4. <br /> 4.Special Handtg Instructions andAdddunai Information <br /> ER Service Contracted by VESTS + 1)W:10966 AREC-WATER(NDMA) 2)w-.10069 <br /> A AZU-DEBIFUEL(NS <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment we fully and accurately described above by the proper shipping name,and am classified,packaged, <br /> marked and labdedrplamrded,and are b all respects in proper condition for transport according to applicable hlemaconal and regional governmental regulations.If export shipment and I am the Primary <br /> Exporter,I m"that the contents of this consignment conform to his terns of the attached EPAAdotoWedgmem of Consent. <br /> I ce"that the waste mintreratim statement Identified in 40 CFR 262.27(a)IN l am a large quantity generator)or(b)('dl am a small quantity gencralor)Is hue. <br /> Geneatoes100erors Printed(Typed Name Signature - Month Day Year <br /> 0 4 10 1 11 ' <br /> -1 16.International SNpments - ' <br /> ❑Import W U.S. ❑Blood from U.S. Por ofentry/exit <br /> Z Tmrsportersignature(for exports only): Date leaving U.S.: <br /> K 17.TansporterAriawxMdgment of Receipt of Materials <br /> 5 Transporter l Pdrtudgyped Name Sgrawne Month Day Year <br /> 0 <br /> c V L <br /> Transporter 2 Prmtedrfypel Name Sig re Day Year <br /> r_ P <br /> 4. 16.Dacmpancy <br /> 188.Discrepancy Indication Space ❑ Duanfity ❑Type <br /> ❑Residue ❑Part!al Rejection 6' [IF uORejection <br /> Manifest Reference Number. <br /> 18b.Aitemate Fadlily.(or Generator) US.EPAD Number - <br /> AUU L 5.[012 <br /> LL Facin ys Phone: <br /> W 18c.Signatum ofAllemate Fadkty(or Geneabr) '� .t Day Year <br /> Q trip, <br /> Z <br /> w19.Hazardous Waste Report Management Method Codes(I.&,miles for hazardous waste treatment disposal,and recycling systems) <br /> 7 � f <br /> .D 'grated Fadl' Owner or Operator.Piktificalkit of reciept of hazardous materials covered by the ryalexcepI as n*in hem <br /> 'nt yped Name - S i )- Month Day Yr <br /> EPAF -22(Rev.3-D5) Pretious editionsare ohsolete; - TO GENERATOR <br />