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20715-
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<br /> ORM HAZARDOUS !.Generator ID Numb( 2.P601 Of 3,Eftt6 wcy Rasponsa P,M a,,�1Pf FTI r �7 `.
<br /> r sTF MAmPEST r. T. +33 a @ 1 1 fi I 'rev) a -:�:,fi0 0 0 9 ` JJK1.
<br /> nerator's Name and Mailing Address Generators Slte Address(It dlflerent than Wiling address)
<br /> T1�,t4CY FORD K-RCURY
<br /> XM AUTO PLAZA WAY
<br /> Twy CA 9W4
<br /> Generators Phone. 2W 8 ,4821
<br /> 6,Transporter 1 Company Name U.S,EPA 10 Number
<br /> A.`i"Y EWRONWNTAL SIMICES C' :3'r' IDO 2 e ? 7 7 f3 l e,
<br /> 7.Transporter 2 Company Name U.S.EPA iD Number
<br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number
<br /> RENEW I VERDOON
<br /> N.ALAWMA STREET
<br /> COWTON Cly : ? CAT 0 & 4 0 1 3 3 5 -2.'
<br /> Facility's none: MMX-71100
<br /> ga. 91b.U.S.DOT Description(includmg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 51,Tota! 12,Unit 13.Waste Codes
<br /> HM and Packing Group(if any)) No. Type Quantity WIJVoh
<br /> 1S�'a,WASTE FLAltAli LE LIQUQ.Pi.O,S, rNAS,DIeSWI,3, FAG III
<br /> C�L7 2. .,.�T. ..
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<br /> 4.
<br /> 14,Special Handling Instructions and Additional Information
<br /> 1r"GEN CY CONTACT.CHE WtREQ 1- 42""NAER(*99 f:128 PROFILE#91:316M G.5,DIESEL PO#
<br /> A,1101511677'APPROPMATE MRSOUk PROTEC71W ECS f1PAENT
<br /> 15. GENERATOR'Sf0FFER0R'S CER11FICATIONr I hereby declare that the contents of this consignment ars fully and aceeratcly dewjbed above by the proper stepping name,and are classified,packaged,
<br /> marked and labeledlplaoardad,and are in all respects in proper condition for transport according to applicable intorn&onaiand national governmental regulations.If export shipment and I am the Primary
<br /> Exporter,I certify that the contents of this consignment conform to the form of the attached WAAdmowledgmenl of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(ir I am a large quantity generator)or(p)01 am a small quantity generator)Is true.
<br /> Generator'slofferoesPri2tedlTypad,NarN Signature... Month Day Year
<br /> � 10.Intcrnatldnat ipments " ,� •
<br /> H ❑Import to U.S. ❑E cd from U.S, Port of entryrexit
<br /> ? Transporter signature(for exports only): Date laving U.S.:
<br /> W 17,TransporlerAcknoWedgment of Receipt of Materials
<br /> Transporter 1 PdntedlTyped{tJlaam�e!1 w signature J,tI r w.] Month Day Year
<br /> a 4-l.t 1 :1 � 1 Cr �"';1 r'��s",•,' fA�F,�,I f.F ''
<br /> QTransporter 2 PrintediTyped Name V Signature Month Day Yew
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<br /> 18.Discrepancy
<br /> 189.Discrepancy Indication Space Ej Quantity ❑Type ❑Residue Penial R*,Ilon Full Rejection
<br /> Manifest Reference Number:
<br /> 18b,Alternate Facility(or Generator) U.S,EPA 10 Number
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<br /> u4. Facility's Phone
<br /> 18C.Signature of Anemale Faciltty(or Generator) Month Day Yens r
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<br /> Zn 19.Hazardous Waste Repor Msnagemen:Method Codes(i.e.,codes for hazard:xts waste treatmem:disposal,and recycling systems) l
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<br /> 20.Designated Facility Owner or Dporaloe Certification of receipt 01 ra7X00S 1110terlats IXWeree by the rnanlfesr except a_noted in Item 18a t
<br /> Printedrryped Name Signature Month Day Year
<br /> EPA Form 8704-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY
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