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Please print or type. (Form designed for use 0n elite if -Ditch) 1106001 cl <br />PAM Annmvarl r1MR Nn 90gn-03o <br />ern Corm UIUU-22 (Hev. 3-1.15) Previous edi lMs are obsolete. ' DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS i. Geneata IDNumMr - • <br />2. Page 1 A <br />3. Emergency Response Phone 14. MNWTraptNurabar <br />WASTE MANIFEST <br />! O FREIGHT J JAMIE HAINES y me _eB <br />1.0990 ROE AVE, MAIL STOP A 605 3233 LOOMIS RD <br />OVERLAND PARY., KS 66211 S70CKTON CA 95205-&110 <br />t20b)466-2901. GENT 313�o <br />Generators Phone: <br />6. Trarreperear I company Name U.S. EPA ID Number <br />HERITAGE TRANSPORT, LLC -TS SIGNAL HILL IPJDG53434i;'t <br />7. Transporter 2 Company Nam U.S. EPA ID Number <br />U. Designated Facllmf Name and ae IlOCrasa .S. EPA ID Number <br />HERITAGE ENVIRONMENTAL. SERVICES <br />284 E STOREY RD PZD081705402 <br />COOLADfGE, AZ 85128-920 <br />Fad' aPhone; `520172; 416'r <br />ga, <br />9b. U.S. DOT Description (including Proper Shipping Nemo, Hazard Class. ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packkng Group (# any)) <br />Quantity <br />WINcI. <br />13. Waste Codes <br />No. <br />Type <br />1. <br />o <br />x <br />G#12 <br />W <br />� <br />2 <br />2. <br />x <br />UN1263,WASTE PAINT,3,PGII,ERG#12G <br />D1N11 141 <br />I <br />Mn <br />IP <br />3. <br />X <br />UN1263,WASTE PAINT,3,PG11,ERG#1.28 <br />D001 :141 <br />D� <br />z s <br />4. <br />14. Special Handling Instructions an <br />1..-4f.:L :99 Q; ; 31 2. W52_�355 .33. 1452.1 9133.5 :� 3 �� ZL <br />R'5 , � c,1. <br />3 t��U 'j1.aERI�� 4 � C4800391J67 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the oontents of this consignment are fully and accurately des above by the proper shipping name, and are dassified, packaged, <br />marked and IabeWplacarded, and are in all respects in proper mnaition for transport according to applicable Internet" and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment coition to the terms of Bre attached EPA Acknowledgment of Consent. <br />I certify that the waste minimaidon statement Identified In 40 CFR 262.27(a) if I am a large quan* generator) or (b) if l am a small quantity generator) is hue. <br />Gemendwsl0flemes PrlmeiName,gna una on y ear <br />// i6 Vf <br />_ <br />16. International Shipments <br />El Import to U.S. ❑ Fxpgt from U.S. Pan of enbylexk: <br />Transporter signature for exports only): Date leaving U.S.: <br />W <br />17. TmnspoderAckno,Medgmantof Receipt of Mai <br />Transporters PrintedRyped Name Month Day Year <br />Wrisporlar2 PrinteNfypea Name y <br />.� ay ea <br />-r- C 02 <br />/1 <br />Discrepancy <br />j18. <br />II��II <br />78a. Discrepancy Indication Space ❑ Quantity y"" yQT1ye► <br />❑ Residue ❑ Partial Rej ❑ Full Rejection <br />{G- <br />n <br />``�I \Y, <br />�L <br />Manifesl Reference Number: <br />18b. Alternate Facility (or Generator) US. EPA ID Number <br />a <br />MAR 17 2015 <br />'s <br />u• <br />Fadl' Ptwne: <br />y� <br />18c.5gnaWre efAftemate Facility Generator) p�A,\/I Month Day Year <br />E V'rVe,.r_,n: <br />mFrT <br />as <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste heatrnent, disposal, and recycling systems) <br />W <br />1 <br />2. <br />3. <br />4. <br />---�+nri• <br />H 7 41 <br />H 1+ 1 <br />20. Designated Facility Owner or Operator. Certification of recaipt of hazardous materials covered by the ma -mist excem rwled in Item 1 <br />Printedrryped <br />ame <br />j. ISignature Month Day Year <br />11 <br />1 i <br />ern Corm UIUU-22 (Hev. 3-1.15) Previous edi lMs are obsolete. ' DESIGNATED FACILITY TO GENERATOR <br />