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Wl <br />'Pi pe <br />f 4 , writer.) <br />asephirit or type. (Form .> <br />for :pp;eliti <br />UNIFORM HAZARDdUS Page 1 <br />Form Annroved. OMB No. 2050-0039 <br />.tVA corm tsm-a (Kev.;3-ub) Previous editions are obsolete. I ' / ( , \,�IGNATED FACILITY TO GENERATOR <br />1 for ID Numtier' <br />2: of <br />3. Emergency respoNse Phone' <br />*1111lariffe t Tracking Number <br />WASTE MANIFESTf. <br />0 6068663 <br />JJK <br />5. Generators Name and Mailing Address Generator's Site Address (If different than mailing address) <br />B & CP SOUJITIONS INC <br />107 VAL DERVIN PKWY <br />StOCKtONCA 962M <br />, <br />Generators Phon <br />.6. Transporter I Clomoptny "Name <br />U.S. EPA ID Number <br />j FRBWLW ENVIRONMEWAL SERVICES IINC. Phow 800-SW3274 <br />C 17101 <br />7. Transporter Company Name <br />U.S. EPA ID Number <br />8. Do-signateaFadlity.�Namo..anO.Sfte Address -----,—U,S.EPAIDNumbr- <br />WERGRIiiN OIL W, DAVIS <br />CAD982440874 <br />44661 ROAD 308 <br />DAWS. CA ON18 <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />AM <br />and Packing Group (If any)) <br />Quantity <br />Wt.Nol., <br />WIIIIII1111110, Ujid (MY WATER)'QQ <br />o0o <br />G <br />223 <br />Z <br />2. <br />4., <br />14. Special Handling Instructions and Additional Information <br />to I*W ii4l �,'and Wor PPE <br />ERG#171 <br />15. GENERATOR'S/OFFEROR%"C,ERTIFICAIION- I hereby declare that the contents of this consignment are fillty and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledtipli" , and -are in all respects in proper condition for transport according to applicable intemational 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 />I certify that the waste, minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator (b) (if I a%,Uaall quantity generator) is true. <br />Gene ceslOfferdrg Prints <br />Month <br />Day Year <br />+ <br />!�� S11a; <br />f k�) <br />16.1riternationalShipmOnts— <br />ElImport to U.S. D Export Port of entrylexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />U W <br />17. Tra0pporter Acknowledgment of Receipt of Materials <br />LE <br />0 <br />Tran ort r 1 Printedrry d Name Signa r <br />Month <br />Day,, Year <br />/U <br />Z <br />Transporter 2 Printedrryped Name Signature <br />Month <br />Day Year <br />18. Discrepancy <br />1 Be. Discrepancy Indication Space Quantity 1-1 Type El Residue <br />Partial Rejection ❑ Full Rejection <br />- Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />LL <br />Facility's Phone: <br />C3 <br />j <br />18c. Signature of Alternate Facility (or Generator) <br />Month <br />Day Year <br />!R <br />ZU <br />v5CD <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLI <br />0 <br />1 <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature <br />onth <br />Day Year <br />.tVA corm tsm-a (Kev.;3-ub) Previous editions are obsolete. I ' / ( , \,�IGNATED FACILITY TO GENERATOR <br />