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Please print or type (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 20500039 <br />FPAF9!MO7..Qp-22 (Rev. 3-05) Previous edi0ons are obsolete. <br />GENERATOR S INITIAL COPY <br />yNIFORM HAZARDOUS <br />1 Generator tD Number :.}: ': j / • = , • , <br />2 Pagel of <br />J Emergency Response Pt one <br />1 <br />4. tAanih!et� Track" Nwnbw <br />(� (� (� �[ e <br />O 21 6 1 S <br />1 <br />x) -:,c c, i c•.,! <br />V -i 0 „v <br />�V,Y�pA�Sr�TppE�MANIFffii <br />51,; n 1 r rl�' Cry I i , iK Ti NF j j he Generatoes Site Address (d different stun mailing address) <br />P11 ISM 62,45 3105 S3 EL OORADO 9-T <br />3TOCKTON CA 9S20E,'0243 <br />;�i1'_3—rit�F� •.33`34 <br />Generators Phone: <br />6:TRIFSPor!"Y'C0TVFTNfrne, ';IFM8, INC. U.S. EPA 10Nurt10er TXF000M09�,0 <br />I <br />7 Trarsporter 2 Company Name U.S. EPA ID Number <br />3 Designated Facility Name and S.te Address— 411- U.S. EPA iD Number <br />1722 COOPER CREEK D <br />UENTON, rX 76208 <br />ra.10177603371 <br />Foul s Ph": <br />9a <br />9b. U.S. DOT Description (,rlckxfing Proper Shipping Name, Hazard Class, ID Nwrkff. <br />10. Containers <br />11 Total <br />12. Unit <br />J. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt Vol. <br />1 4 G , �. <br />IJ , <br />a <br />(P--CNLORCiRENZOTRIFLUORIDE) <br />— <br />� <br />3 UN 1993 PDS III ( 0001) <br />Z <br />2. <br />w <br />(7 <br />J <br />4 <br />14. Special Handfeg Inswxb" and Addmonal Infonnatlon ',)h M3 r 1 <br />t ) f>:)lGW8 <br />114 HR EMERISFNCY 600-468--1760 (SAFE Fy KL FEN '14138) <br />iK t)J1T14' 0 TO I;�;F 91JBSEOUENT CARRIERSt '+0067, 410.38, 8272-9, 35399, 87°385 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that Me contents of this consignment are'uly and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled'placarded, and are n all respects in proper condition for transport according to aWiabie ntetnabonal and national govemmental regulations. If export shipment and I am the Pnrary <br />Exporter, I certify that the contents of this cons nment conform to the terms of the attached EPA Acknowledgment of Consent <br />I ceMy that the waste muninwation statement xfentfied in 40 CFR M27(a) (a I am a large Quantity generator) or (b) (RI am a steal quantity generator) a tru. <br />Generator'V01fanYs PrntedTyped Name Signature MMM Day Year <br />� <br />18. International Shrpiwts <br />❑Import to U.S. ❑ Export from U.S. Port of enaylexR: _— _ ------ — <br />Z <br />Transporter signature (for exports only): Date leavtng U.S.: <br />17, Transporter Adurowledgttrent of Receipt Of Materels <br />Transporter 1 PrintedlTyped NaSignature r,1pt h Day Year <br />Nam <br />O <br />a <br />� <br />Transporter 2 Pnnte&Typed Name Signature Month Day Year <br />X <br />H <br />8 Discrepancy <br />�1 <br />I Ba. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue �❑ Partial Rejection J Full Rejection <br />Manifest Retererce Number' <br />18b. Alternate Fauhty (or Generator) U S. EPA 0 4umber <br />J <br />U <br />LL <br />Facility's Plane: <br />Month Day Year <br />w <br />18c. Signature of Alternate Facility nor Generator) <br />F.. <br />Q <br />2 <br />19 Hazardous Waste Report Management Method Codes (i e., codes for huardous waste Vestment, disposal, and rft-rjwg systems) <br />LU <br />0 <br />1 <br />2. <br />T <br />3 <br />20 Designated Facility Owner a Operatm CermBcabon of receipt of hazardous matenats covered by fest except as need in Item 18a <br />r nted yped Name 5gnatiue Menta Day Year <br />FPAF9!MO7..Qp-22 (Rev. 3-05) Previous edi0ons are obsolete. <br />GENERATOR S INITIAL COPY <br />