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r <br />Please pont or type. (Form estgned <br />for use on elite (12 tilt ewntel) rorm mpproveu. voeD rvu. cuou-uuoy <br />UNIFORM HAZARDOUS <br />1. Generator ID <br />2Page t of <br />3: Emee2nResponse Phone <br />4. Manifest Tracking Number <br />WA$T91A I NIEEST `$1953007883508 <br />�[ <br />JJ <br />5. Genera `tis 1464 a and Mailing Address & C PAINTING LI INCGenerator's Site Address (if d'ffferent than mailing address) <br />107V Rpp(� PKW <br />6 . CA <br />M0=0 95200 <br />09-982-0422 <br />Generator's Phone <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />ES IM CARM0171017 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated`Facility Name'and Site Address iZIRGREEN ®IL 'DAVIS'— ._ U.S. EPA ID Number 2 74 <br />44551R <br />DAVIS, CA 9W1 <br />610-795-4400_ <br />Facilli es Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />r 1. T <br />12.'Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (ff any)) <br />Quantity <br />Wt.Nol. <br />O <br />1. <br />1 <br />505 <br />z <br />2. <br />W <br />C7 <br />' <br />3. <br />_4. <br />14. Special Handling Instructions and Additional Information <br />-ERG <br />171 <br />15. GENERATOWS/0FFEROR'S CERTIFICATION: 1 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 iabeled/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 EPAAdmowledgment of Consentoe <br />in 40 R 262.27(a) (if lam a large quantity generator) or (b) (if I am all entity generator) is true. <br />I certify that the waste minimization statement identfiad CF <br />Generato Offerors Printed/Typed Name Signature"' MonthDay Year <br />J <br />i— <br />16.memational Shipments <br />❑ ❑im rt to U.S. Export fro Port ofentry/exff <br />Transporter signature (for exports only): Date leaving U.S.: <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />1 <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />O <br />to <br />--- _ ♦ — - — -- — ;_ _ r <br />Z <br />Transporter 2Printed/ryp Name Signature Month Day Year <br />it <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue Partial Rejection El Rejection <br />Manffest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />W <br />Facilitys Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />W <br />1 <br />1 i 1 <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certficabon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printe, /Typed Name Signature r Month Day Year <br />r d <br />i �' ( <br />enA>aslv�rP��h .. <br />tr/-xr-orrnoiuu-zztr,ev.":)) rrevious eamons are oosoiere. DESIGNATED FACILITY TO GENERATOR <br />