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Please print or type.(Form designed for use on elite(12-pilch)typewriter.) Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page I of 1 EmergencyResponse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST a �Z , 1. 1-800-424-9300 00499379' 'JJ.K <br /> 5.Generators Name and Mailing Addmui,�A&, A,-7,0 -te,,* <br /> nGenerators Site Address(it different can mating address) <br /> /'7/.,) IV 4/lee,,4 ozv� <br /> ,57-eeol <br /> Generators Plaice: 09- '(17J`' <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> PACIFIC COAST LACQUER CAROWl-94837 <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 /> PACIFIC RESOURCE RECOVERY CA0008252405 <br /> 3150 EAST PICO BLVD. <br /> LOS ANGELES, CA 90023 <br /> Fxdlitys Phone: (800) 499-7145 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Con ainers 11.Total 12.Unit 13.waste Codes <br /> HM and Padang Group(dany)) No. Type Quantity YA.Nai. <br /> % 3N1263, WASTE PAINT RELATED MATERIAL, 3, C 001 F D03 FOOS <br /> p 3GII, RQ, (0001) <br /> 9 / DN 3o G '14 <br /> z ON RCRA HAZARDOUS WASTE LIQUID (WATERBORNE 133 <br /> LEANING SOLUTION) (CALIFORNIA REGULATED / OF G <br /> 3. <br /> 4. <br /> 14,Special Handling Instructors and Additional Information <br /> 9bl) AP# 6329 9b2) APN 6339 <br /> GLOVES GOGGLES & PROTECTIVE CLOTHING <br /> 'ERG#: bbl) 128 91 NONE <br /> TRANSPORTER 1 PHONE 4 1-800-752-1666 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the pmper hilic ng name,act are classified,packaged, <br /> marked and labeled/pleaded,and are In all respects In proper condition for transpun according to app8ceble' nalanit n ria vemmen uta' s.lt export shipment and I am the Primary <br /> Exporter, certify that the conten6 afihis consignment conform to the lama of th attached EPAArknowled9 aril of sent. ,.1 <br /> I cem y that the waste minimization statement identihad in 40 CFR 262.27(a)If I am a large quantlry genera <br /> )or( <br /> (b) am a i geneafor <br /> Ga.ralafslOfletofs PrintedRypndName Signatu Month Day Year <br /> Se F-� Jslog Ile 109 <br /> ZJ 16.International Shipments <br /> F ❑Impact to US. EVcrtftom U.S. P.4 of nuy/eot: <br /> Transporter si9nalure(for eons only): Date leaving U.S.: <br /> w 17.TransporterAcknaatedgment ofFlacito of Materials <br /> Trans idecifTyped Name t Sig re Month Da Year <br /> `°CEJ ,t � 5 <br /> Z Transporter 2 Printed/Typed Name S' Month Day Year <br /> 4 <br /> K <br /> 1-- <br /> 1 18.Discrepancy , <br /> 18a.Discrepancy Inditabon Space ❑ ouanfity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facilil Phone: <br /> 18c.SgnaWre of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> -- Z <br /> y19.Hmrdous W1 Report Management Method Codes(i.e..ccdesjDr hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3. .- 4. <br /> 20.Deslign6tedicaolity,C6er or Operator Certifira6on of rete alhara materials covered by the manifest except as noted in Item 18a <br /> 1 PomteMyped me SignaNre Month Day Year <br /> EPA Form 0 22(Rev.3-05) Previous editions sot . DE ATED FACILI STATE(IF RE UIRED) <br /> 10565.0287 <br />