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ieasiLprmLq..r type. (r-orm aesignea <br />Tor use on elite (1 2 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br />4 <br />RIFAM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14. Manifest Tracking Number <br />PRR % <br />MSTtMANIFEST 1—EIOO-499-71451 008661866 JJK <br />1 <br />SuGlWheptoes Name and Mailing Address Generators Site Address (if different than mailing address) <br />74- <br />RGHt, TRUCK PARTS & EQUIP <br />1016 S. WILSON WAY <br />aS 0 K <br />Gen rje hojON, CA 95205 <br />- <br />6. Transporter I Company Name U.S. EPA ID Number <br />PACIFIC COAST L-0,CQUER CAR 194837 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />F <br />8. De.,signatedFaclity Name and Site Address U.S. EPA ID Number <br />PACIFIC RESOURCE RECOVERY CAD008252405 <br />3150 EAST PICO BLVD. <br />LOS ANGELES, CA 90023 <br />Fadill es Phone: 4800) 499-7145 <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />t2. Unit <br />HIM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />NO. <br />Type <br />X <br />1•UN1263, WASTE PAINT RELATED MATERIAL, 3, <br />D001 F003 F@05 <br />o <br />PGII, RQ. (D001) <br />214 <br />DM <br />G <br />LU <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />9b1) AP# 6329-96— AP -11 ---- <br />GOGGLES & PROTECTIVE CLOTHING 24HR EMERGENCY CONTACT: KIRK WALDORF <br />128��� - <br />__JRANSPORJER I L52 <br />15. GENERATOFVS/OFFERon 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, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />certify at the waste minimization statement identified in 40 CFR 262.27(a) (If I am a large quantity generatoUr (b) (ffjjm a small quantity genre r) is true. <br />erat9es/Offeroes Printed/Typed Name Si ar/ MOX Day Year <br />J16. <br />r <br />Int5mational Shipments <br />F-1 import to U.S. ❑ Export -from Pod: of entry/exit <br />3 <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. TranspoqK60alowledgment of Receipt of Materials <br />OC <br />Transpbr j PrintsaDlped Name rture Month Day Year <br />Z <br />C <br />Transporter 2 Printed/Typed Name re Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space F-1 Quantity El Type El Residue ❑ Partial Rejection 0 Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />0 <br />rah <br />Facilitys Phone: <br />Uj <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />W19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1 <br />2. <br />3. <br />4. <br />20. Designated Facdily Owner or Operator. Certification of receipt of hazardous materials covered by the manifest VcepA as noted in Itern_Aa <br />PrIntedffypedName Signa re Z 7 Month Day Year <br />Forffi j? L7 <br />EPA 8700 h - '. P <br />-22 -nrY l5ravinim �­lfr <br />Wh5fUNATED FACILITY TO GENERATOR <br />