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UKH:CRY -�L.LARDOUS <br />1 Generator 10 Number <br />2 Page I of <br />3 Emergency Response P'-t—a rac.-ny <br />0 0 8 9 5 8 9 2 7 <br />W-7 <br />C� �' F ON - <br />7 1cl <br />Address Generator's Site Address (if different than — <br />ice.Ery0ronmental, Incf. <br />' ,-'c- 'Q CA -v <br />16CRO Sojilh C-amiro —meal, 31-ilteJ <br />0 <br />C-4", a 1:15 P non S <br />s:: -*.e? ' Company Name J,S EPA ID Number <br />rR Er—ronmerit"al, Inc <br />T rars-orte, 2 Company Name US FPA ID Number <br />8 Designated Vacuity Name and Site Address US EPA ID Number <br />4k9yCCOI, LLIG — <br />r-025 S; Faetor AVe <br />-jrna i,7 <br />ga <br />9b U S DOT Dwscitpiton (including proper Shipping Narie. Hazard Class. ID Number. <br />10 Coftnn-it <br />total <br />12. Unit <br />1, waste Codes <br />No <br />Type <br />jjM <br />and Padang Group (it any)) <br />Wt Not <br />I Vjrl- i; HaZal -10 -1 2E tEl LJQ WO I 01ty V-'BtEl rl <br />Mort-Rt.P-a Hazan:lous wage Solic I uieea ")11 Flijar; I <br />3 1-127ar(lQuE V4389 G( id (IA -0-0 "WD91"ll) <br />67 <br />14 Special Handling Instructions and Additional Informal <br />L 18e 3q X <br />"­' SLI 4C 1=u- <br />15 GENEPATOWSIOFFEROR'S CERTIFICATION, I nereby declare that Ow contents of er-s,: r fro ant accurately doscrtbod sh,piwj name aid are d4stiAnd. packaged <br />and vAleftlacarded, and are in all respects nftwr condition Iry transport i i -le mternaborial and rkaWal 7wernm4ntil teguiationS It export shipment and I am U* Primary <br />certify that the contents of this consignment conlorm to thp terms of the z- —-c?fnenlolfonsenl <br />-Crify that the waste rninintizalion statement dentified it) 40 CFR 262 27(a) (it I am a large quantify generator!, or MV am a small quantity generator) is Ili <br />Ganerator'VC)fferors PtintetVilypi N Signa Month Day Year <br />13 <br />j <br />J 16 Internet at Shipments Import to U.S. Expert from U S/ P/(Yt Of e"Wexil: <br />Transporter signature (for exports only). Date leap V U S. <br />IC 17 Transporter Ackrowledilmem of Receipt of Materials <br />13 <br />Transporter I Prinled/Typed Name -%naturp Month Day Yea, <br />L Transporter 2 I"mirtidayped Name Squiture Month Day year <br />e. <br />18 D,sctepancy <br />18a Discrepancy Indication SpaceTWO Res,due Partial Rejection Full Reledon <br />Manifest Reference Number <br />I 8b AfteMale Facility (EN Generator) US EPA 10 Number <br />Facility's Phone <br />I Sc Signature of Alternate Faoky (or Generator) <br />Month Day Year <br />19 Hazardous Waste Report Management Method Codes (i e. nodes for hazardous waste treatment diWr.,Il, and recycliN systems) <br />T <br />20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the martifest,!xcepl as Wed in Item 18a <br />PrinIRTyped —Name Sgiature Month Day Year <br />tiA Form 870D-22 (Rev 3-05) Previous editions are obsolete -FACILITY TO OESTINATION STATE (IF <br />