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•03-04-'15 15:52 FROM- les Environmental 661-322-88ft T-454 P0009/0012 F-956 <br /> Please print or type.(Form designed for use on 01,10(12-pitch)Typewriter,) FmmApprovad.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Gegaralar lb Nambef 2.Pagelof 3.Emergency Response Phone 4.ManifcatTraokingNumbar <br /> WASTE MANIFEST CALOTA35FtFfTy 1 209-4W-04W 013435267 A <br /> 6,Gen"Xers Name and Mailing Address Generawrs NO Addrew To 01nerent Than making address) <br /> PACIFIC SOUTHWEST IRRIGATION <br /> Bo-72 S.JACMPJ RD. <br /> STOCKMA1.CA 95215 <br /> Geberalora Phone: 209.d60-O450 <br /> 6.Transporter 7 Company Name U.S.EPA ID Number <br /> George W.Lwy,Too, CAROD0047019 <br /> 7.Trenspoder2aC�ampanyName @qC. U.S.EPAIDNumhar <br /> 6.DesA09BY Ya Name and O�RFON INU.S.EPAID Number <br /> 1610 W 17th Street CAm.T.=n <br /> LONG BEACH,CA 90818 <br /> FscjOye Phone: BDM7-6729 ' <br /> ea, ab..U.S.DDYDcscdpgon(including Proper 61fppingNamo,Hazard Gass,ID Number, IO.Containers 11.TOW 12 Unit <br /> HM and Paddng Group(if any)) 73.Waala Codes <br /> No. Type quantity WLNoI, <br /> h •K 1. USN 11133 W0.STE FLAMMAEILE LIQUID D. o.s. (MheGNe'o) 3. PGii DM /0 p �1 <br /> w <br /> 3. <br /> lAflF- <br /> 4. PR 0 2015 <br /> ENV RON AENTT <br /> 74.Special Handlirm IneWcgansendPGdigonallnfarmedon <br /> l ERGV120 TelfaRydroBlm&Methyl Ethyl Ketone PNC pipe glue <br /> USE GLOVES PROF1LE0 G..�I INVOICLV '�5 C)37 <br /> 76. GENERATOR'SfOFFEROR'S CERTIFICATION:(hereby de <br /> dme Nat The contents aides mnsignment2la rally and acsurdlelydescdbed above by the proparshippmg name,am ere Assided,packaged, <br /> marked and laheladlplaardad,end grain aurespe0s in pmparmndd0on forhmspadaccording to applIcable Inh madonatand national governmental regulations.If exportsNpmcnland I am ThcPdmaly <br /> Exporter,I cc*detthebontents of ft conslgnmento mfatm to de tdmtNr Me attached EPAAcknowledgmentafDorment <br /> 1 Willy That ft%Vasla minim'¢a8on statement Identigedin 40 CFR 262.27(x)fdl am a large quentily ..slor)or(b)(fl am asrnag Quan6ydeneralor)is hue. <br /> Generators/OfferoraPthged(Typed Name S)gnanne Monty Day Year <br /> < . <br /> ai 57, Ae r� IS <br /> —I <br /> f6.Inlemadanal3hlpmene <br /> '— ❑Import to U.S. ❑Eaportfmm U.S. Podolenlryfed- <br /> TranspodersignaNre(foreKpoitHonIA: Data leaving U.S.: <br /> V.TrampoaerAdlmAedgmeat of Receipt of Materials <br /> OTianepur6arl dnt ypedN Signelore Monty Day Year <br /> a <br /> Tmneponer2P ped Name of <br /> Sf naturet5 <br /> a g Mond Day Year <br /> r•- <br /> T16,Discrepency <br /> 76x,DIst7epanrytnGnaUom SpaaOf t <br /> ❑auanuryova ❑Resides ❑PeNel Rejemion LJ Full Rejection <br /> 16b.Altemale Farmry(orGaneraWr) Manifest Reference Number. <br /> U,S.EPA ID Number <br /> U <br /> W4 Facigys Phone:' ' <br /> juu 18c.Signature ofAl4maleFaciGry(orGefremtor Month Day Year <br /> a <br /> . z <br /> I9,Hazardous Wads RepodMenggement Method Codes(e„codes forhataldouawaste treatment,dispmal,and mcyding systema) <br /> 12* <br /> 3 4 <br /> ��. <br /> 2o.Designeled FaoTiy Olmarnrgperalar.CetV7ca0on ofrsmiptafharatdous matedaB covered by Thema a• plaandedin Ilam 18a <br /> IWII Pgntedrryped Name rg are month Thy Y <br /> qu— <br /> EPA Fofm8700.22(Rev.3.05) Pfeviouaeditionsare obsolete. GNATED FACILITY TO DESTINATION STATE(IF RE(2UIRED) <br />