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Form Annroved. OMB No. 2050-0039 t -lease pnn[ ur type. truini ueaiyt UNIFORM HAZARDOUS icu uoc u.. cu c icNu�„ ,yr....,,. 1 • Generator ID Number 2. Page 1 of 3. Emergency Response Phone i 4. Manifest Tracking Number }q j �( 0 0 7 6 9 5 4 Z K WASTE MANIFEST C A D 9 8 2 5 0 8 2 5 1 09.889,550 NJ 5. Generator's Name and Mailing Address:. Generators Site Address (if different than mailing address) hied Crocer3 UNfied Cracers , Agn: pat GUwrTnetsy, 52CO Sheila Street 1990 BOO Rd. Cgmrrwce CA 90040 Stocktcn CA 95215 Generators Phone: 7 < _ t 6. Transporter 1 Company Name U.S. EPA ID Number P ! Fiat Mat Trans, Inc. C A T C 8 0 0 '•;1 `3 O,i' 7, Transporter 2 Company Name U.S. EPA ID Number l� 8. Designated Facility Name and Site Address U.S. EPA ID Number Crosby & Overton 1630 W. 17th Street l.cr:g Beach CA 0-08 l3 CAD 0 2 8 4 9 0 1 9 Facility's Phone: g 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. 195''0, WASTE Aerosols D001 ! 331 X343 - X�N X 2.1 W 2. W RE 3. JUL f 4. ENVIF ON ENT L HE LTH g DEPtRTM�NT t4,Special Handling Instructions and Additional Information 9.b..1) Aerosols Profile# 51192 ERG: 125 Gloves sr Goggles 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby 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 EPAAcknowledgment 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) Jif I am a small quantity generator) is true. Generator's/ ors Printedlfyped ame Signature � Month Day Year r i 041 !7 -J j 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: Transporter signature (for exports only): Date leaving U.S.: (i W 17. Transporter Acknowledgment of Receipt of Materials � Namg Signore Transpo er PrinteX-/ i ` Month Da Year Y � ' �� / Qransporter 2 Printed/Typed Name Signatur / Month Da Year Y F- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue Partial Rejection ❑ Full Rejection YI@ RET'ERfNCED WASTE WAS RECEIVED. HANDLED AND STORED FOR SUBSEQUENT OFFSITE !)ISPOSAL. TREATMENT OR REUSE CROSBY k OVEXTON, INC. OPERATES THE FACaMffilhW Reference Number: 18b. Alternate 1F6BAItj1(1;rQ�A xm1 T1lE EN MENTAL PROTECTION AGENCY IN ACCORDANCE Wmi 111E PROVISIONS OF U.S. EPA ID Number nIE RESOURCE CONSERVATION AND RECOVERY ACT OF 1976 TOGETHER WITH APPLICABLE Q1DERAL AND STATE REGUTATIONS. CROSBY A OVEtTON HAS All. OF THE NECESSARY WASTE HAS BEEN D <L Facility's Phon WASTE AND ALL THE ay Year W 18c. Signature &pity (or Generator) JtT Q Z 55 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1. 2. 3. 4. 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the m hifest except as noted in ItemlfAa Printed/Typed Name Signature .,. Month f Day Year GAA Gnrm 117nn-90 114Pv 14-n51 Prgvinim Pdit(nns are obsolete. nPSIr NATFn FArll ITV Tn GIRNERATOR