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V <br /> Please print or type.(Form designed to <br /> rpse on elite;( -pitch)typevailec) _ �- Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1;GendialarlD Number 2.Page 1 o 3.Emergency Response Phone 4.Manifest Tracking Number <br /> ,�+ _/, g'p�'?r �:. <br /> WASTE MANIFEST CraLCC'LSY87:' E .:" __ tip11343u32>� hr JJ,K <br /> utl� . <br /> 5.Genemloes Name and MallingAddress GeneraWds Site Address(if different than mairing address) <br /> PACIF/ STOGI T N,GA 5215 Rit',hi1GN RECEIVE® Y <br /> I 8372 S.JACKTGN RD. i <br /> 9l'GCKTrOhI.Ch 95:15 •}. <br /> Generaloes Phone: 2C9-dE0.0450 'Jd <br /> 6.Tmnspoderl CompmryName U.S.EPAIDNumber - <br /> George`,"d.Lowry,Inc. APR O S 2015 r°FiCDDn47C1j <br /> 7:Transpomer2 Company Name � U.S.EPA ID Number <br /> G���tSF - n� s. E C-4 <br /> �'ccool U ll n, <br /> 8.Oet7cR7LP�1`� Nrere t�dua ddress Hr �i f)FPART;IAFNT •S.EPAID Number <br /> c'YiCoJ ALW4tE0A 9t. G:''i;"^r.•3,'. <br /> r0rd15TOPi,CP. 0=2 - <br /> Faultlys Phone: 310.537.7100 <br /> Its. 9b.U.S.DOTDescdption(including Proper Shipping Name,Hazard Class,ID Number, 18.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Gmup litany)) No. Type Quantity WLNM. <br /> of y 1' UNI 199.1 kthnSTE FLAhBG4^PIS-Ll'?IJID I93eelllee Clee01 MIF) 3 PCIU -`Ohlc <br /> O <br /> =001) r,J"_ice.` <br /> J , <br /> p'A' unn rr 1(11 AlIFIED <br /> W 2. IRIS 7VA f Ill Ung <br /> CiYriLll�C/�;f , r r L!E I I 1 <br /> SIL <br /> C FOR RE IPU : 1";1S AT Tr, _II I <br /> rl r'y;!i i .',cl)aSPTI?h, 1 <br /> 3. sTi ii,;ti tg_trJri; ,ivn\ r <br /> CALIFORNIA,!{ aNr r i <br /> PERMITS TO RFS('' f n •;i to dYl r�� � . <br /> T <br /> QUALIFIEU.UUm tLr:.ilu . ' '-'TQ : 3352 <br /> ... 1 <br /> 14.Special Handling lnsmrclions mWAddiUmal information. <br /> ;3A,SGL1FtlE DIESEL fxIbr USE 68F6 appnoved G3reiy prepaullons <br /> a� )I <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:1herebydeclare that the conlenls of this consignment are fully and accurately described above by the propershlpping name,and are classified,packaged, <br /> markedand labeledfplacarded,andamin all respeclsin propercondillon forbansportaccording to applicable internalionaland national governments]regulations.Ifexponshipmentand l am the Primary '•:."' <br /> Exporter,I ceAfy lhalthe tonlents of this consignment conform to the terms of the attached EPAAcknowledgmenl ofCensenl. <br /> I certity lhal the waste minimization statement identified tn46 CFR 26227(e)(if l am a large quan6lygeneralor)or(b)(if]am a small quantitygeneraka)is We. <br /> GeneratoeslOffemis PrinledJRyped Name Signature / Month Day Year <br /> .^S <br /> rtv(l ' Al <br /> —m 16.Informational Shipments <br /> r ❑import to U.S. ❑Expon from U.S. Podofenbylexit <br /> Trenspodersignalure(forexpods only): Dale leaving U.S.: <br /> w 17.TrensporterAcknowledgmenl of Receipt of Materials <br /> Tmnspoder ,Qrinl drrypedName Signature/ ,O / /;/ Monh Day Year .i <br /> = Tmnspoder2P'nted?yped Name <br /> �� ( n Signalu s -•, f Month Day Year <br /> � f�d'.9r.%Y3 <br /> } 18.Discrepancy <br /> Ilia.Discrepancy Indication Spau ❑ C <br /> Quantity ❑Type 1:1 Residue ❑Padial Re eclion <br /> I ❑Full ReJecfion <br /> "- - Manifest Reference Number. - <br /> 18b.Allemale Facility(or Generator) U.S.EPA ID Number <br /> U ' <br /> ra Facrilys Phone: <br /> w 18c.Signature afAllemale FacTly(or Generator), Month Day Year <br /> Q <br /> Z <br /> w19.Hazardous Waste Report Management Method Codes(i.e.,codes four hazardous waste tmalmenl,disposal,and recycling systems) <br /> D.Designated Facility Owner or Operator.Ceifillmimn of recelptof hazardous materials ca meed by the manifest except as nded in Item Igo <br /> Prinledrryped Name / Signature Month Day Year <br /> EPA Form 8700-22(R&3-05) Preefts`edilionsare obsolete. `" `_DErSICNATEDFACILITY TOGENERATOR <br />