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Sep. 3. 2010 9:4 1 AM GB Industrial Spray Inc, No, 4)27 P. 11 <br /> Please print or type.(Form dosigned for use on elite(12-puch)typewriter. tlli., N Form Approved.OMB No.2050.0039 <br /> HAZARDOUS UNIFORM::ARDOUs 1 1.Generator ID Number <br /> 12,Nei of Y3—.Eme stF��, 4.Manifest Trachij Number <br /> ri�el%q <br /> WASTE MANIFEST <br /> i <br /> 4 Generator1-- 000,51-16r- 48 FLE <br /> 15.G�Leir4&4 Nam 'ard Mail] <br /> � <br /> ,!.diffgrenf(han mi address) <br /> j <br /> Gellefai i <br /> 6.TranjporignJ�Coqiqat:y.irame <br /> U.S.EPA to Number <br /> 7 Transporter 2.G.O.r.nqanY,Nanrq,i,< <br /> U.S.EPA ID Number <br /> 8.Wri FaaityNemO.and S0Addr6s1-i'5i..-'T <br /> U.S.EPA ID Number <br /> A <br /> Facility';Phone: <br /> 94, 9b.U.S.DOT Basorlption jiridudkig Proper Shipping Name,Hazard Class,ID Number, 10.Corft 11.Val 12,Unit <br /> HIM and"Grotip(lani N" Quantity VVI.No�. 13,Waste Coda$ <br /> 4, <br /> 114.,Spempl."andling Irtstriti and Additional Information <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the"tents of this consignment are fully and accurately described above by the proper shipping rame, nd'are'6paifiecl,packaged, <br /> marked and abeled/plawded,and are in ail respects;In pi cordilion fol transport according to appl'cat)l@ international and national governmental regulaillons.It export gnipmi arq am the Primary <br /> Exporter,I certify that the contents of INS consignment conform to the lerms of(he attached EPAAcknowfedgmeril of&Asont <br /> I codify that he waste minimization statement ideplifted In 40 1262 27(s)(f I am a large quantity generator)or(b)(it I am a small qi!!*generator)is true. <br /> C*nerator's/Offeroies Prinle.d/Type-dName <br /> iiiMl 16.International$111pMeniExw lill"M U.S. Fort of entry).at: <br /> El import ku.S., ❑ <br /> Transporter amnature for exports onIA: Dale leaving U.S.: <br /> 17.Transposer Acknov4edgmenA of Raceiptaffiliatairials <br /> Tratr4orer 1 Printed/IYW Name 61gi month Nw— Year <br /> I. <br /> Transporter 2 PrinbWyped Name <br /> sl ' Month Day. yi1i <br /> 16.Discrepancy <br /> 188.OiSvispancy Iri Space El Quantity 11 Type ❑Residue Partial Rejeci El Full R.*11i <br /> Mimi Reference Number. <br /> 18b.Allerri Facility(or Generator) U,$-EPA ID Number <br /> ItIc,Slignature of Nernato Facility(or 11-reratoo Month Day Year <br /> ;9.Hazardous Waste Report Management Method Codes(i.e,,i for hazardous waste Iroalmi disposal,and recycling systems) <br /> LU 7- <br /> 3. <br /> 20.Designated Facirity0"Of OrOperator Certilleationof receipt Cfhazardous msiedaJs OWM by On manifest"oeplas noted in Item 16a <br /> nledlfyped Name <br /> Signature Month Day Year <br /> Form 3700-22(Rev,3.05) PivIii editions are obsolete, <br /> DESIGNATED FACILITY TO GENERATOR <br />