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Vlease print or type,(Foh designed for use on elite(12-pitch*writer.) • ORDER # Form`pproved.OMB No.2050 0 <br /> UNIFORM;HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifestumber <br /> i <br /> *WASTE MANIFEST C A D 9 6 0 8 8 7 3 6 8 1 800-535-5053 10004279 JJ K <br /> 5.Generators Name and Mailing Address Genemloes Site Address(V different than mailing address) <br /> E.R. CARPENTER CO <br /> 17100 S HARLAN RD <br /> P.O. BOX 2791 LATHROP, CA 95330 <br /> Generators Phone:. <br /> 6.Transporter 1 Company ame U.S.EPA ID Number <br /> U1kVAR USA-SNC. C A D 0 1 0 9 2 5. 5 7 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> UNIVAR USA INC. CAD 981382849 <br /> 8.DesiigCgna��te(d Facility Name and Site Address U.S.EPA ID Number <br /> 512M51 <br /> ISE gOAD <br /> RETTLE3�N, CA 93239 <br /> Facir 'a Phone: r r a_19 _ C A T 0 0 0 6 4 6 1.1 7 <br /> ga, 9b.U.S.DOT Description(Including Proper Shipping Name,Heard Class,ID Number, 10.Container . 11.Total 12.Ung <br /> HM and Packtn Group(g any)) - No, Type' Ouandly, WLNc9. 13.Waste Codes <br /> 1.`TOXI `SOLIDS, ORGANIC, N.O.B. <br /> ,x ,:,(TOtIIBNE DIISOCYANATE), D M »!O <br /> 6.1, UN2811, 2G:III, (ERG#154) (� _ <br /> w <br /> z z. <br /> w <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> 1. CAS75038 <br /> PLACARDS PROVIDED BY CARRIER/SHIPPER IES/NO DRIVER SIGNATURE <br /> *** ZR CALLER MUST IDENTIFY UNIVAR USA AS REGISTRANT **** <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the content of thisignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transpod g to applicable international and national governmental regulations.Rexpod shipment and I am the Primary <br /> Exporter,I certify M�t the contents of this omsgnment conform to the terms of the attach EPAAcknowledgment of Consent. <br /> I certify that t,e wash,minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(81 am a small quantity generator)is true. <br /> Generato eroes Printed(ry, Na a Sign Mont, Day Year <br /> ,yam- r0ila 6 <br /> 16.IntemIlbraTShipments <br /> � ❑Import to U.S. ❑Export from U.S. Pod of enbylex8: <br /> Z Transporter sgnafure(for exports only): ..Date leaving U.S.: <br /> w 17.TmnspoderAdToWedgmentof ReWptof Materials <br /> Tran�er 1 Prnted(ryped Name Sg Mont, Day Year <br /> N `0 70 �O a 41 <br /> z Trans 2P dfrypad ame Sgna Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ype ❑ResideC � ❑Partial Releribon ❑ ull Rejection <br /> � t1t �1 j`lts� :1 l4Gr. �,��. 1. .C` C.A�,+ t� L��t111c11C�_c.� ;�a� ( �t�i1'�\� t� t' ��! „•��.�i`) <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number' <br /> J <br /> U y <br /> LL Facilitys Phone: <br /> uu led.Signature of Alternate Facility(or Generator) Monts Day Year <br /> Q <br /> hPaclity <br /> t Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 2. 3. 4. <br /> ner p t r C g cation oceiplof hazardous materials covered by the ma noted in Item 18a <br /> Sign re a Y r <br /> i <br /> EPA Forma 0- 2 ev. -OS) ious edi ons re obsolete. DESIGNATED FACILI O G NERATOR <br />