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,1822 <br /> .136621 <br /> ,�*or orm des ed for use on elite 12-pitch)typewriter.) Form proved.OMB No.ZD50.0039 <br /> 1.r a;Zator 0 Number 2.Page 1 of 3.Emergerwy Response hone 4.Man t Tracking Number <br /> u WASTE <br /> i�F <br /> FeST DCOWUS CA RQQOOt37239 2 (8771 577-2669 0 0 7 7 516 4 7 JJ K <br /> 5.Gensfator's Name and Malang Address Gen eraWs Site Address(B Oftent Mmr mang address) <br /> Hone Repot C/O PSC MR. HM Depot CSR )b8t1= DEPOT 1911116 <br /> $151 San Felipe WE )SPOT 1911/16 251 CIIIIIERCE RVE <br /> Ge"MOROW TX 77151 (151)313-7344 HRA4TECA CA 115331 (2411825-3139 <br /> B.Transputer Company EPA ID Number <br /> 219t Century Environmental Management of Nevada, LLC NVD960695338 <br /> 7.Transportet2 panyNama U.S.EPAtDNunrbar <br /> B.Oesk�rreled FacBhy Menne Ad�trse U.3.EPA ID Number <br /> GEwwt Ben RL 11&7, LLC ADA PSC EHVINWf WAL SERVICES <br /> 11855 VHITE ROCK ROAD <br /> FadwaphoneJAM COMM11 42 (411) 351-MIC C-09 OB84IB3 <br /> 9a Ob.U.S-OOT DesciWon(Including Proper Shipping Name,Hazard Gass,ID Number. 10.Containers 1t.Tote) 12.Unr1 13.Waste Codes <br /> HM andPaokN"W(Bsny)) No. Type QuprNAJVdt. <br /> 1• U111151 W STE IIEROSOLS, FLWILE 2.1 DOT Sr 11291 14(1117-111 Di81 t,Doi5 t Hui <br /> D 00 <br /> 1115 1117 <br /> 2. UN1911 WASTE F AMILE LIQUIDS, H.O.S. (RCETK, METHYL ETHYLj�� P Nil 1135 <br /> RQ KETOSE) 9 P6II (FLASHPOINT-Z/.1/t:) 9Q(IMD1=141) (�Q <br /> 3. <br /> x <br /> a. TE p <br /> x ) r►/` <br /> 14. pe nsauctioms aWAdMord Wormdon <br /> (1) 2.1-84 - E15(121) AEROSOLS-RC RTIO (2) 3-14 - ERM12/) FLRMIULN-41111FA,141—LISAM- <br /> 16. GENERATOR'SIWEROR'S CERTHFICATION:I hereby declare that the corterils of this consignment are M11y and akry described above by the proper Ing name,and are dessMad,packaged, <br /> marked and lam end are In all respells In proper condition For transport anx W!N to apptiAh Intmmadonal ami national gamemmental regulations.It export shipment and I am the Primary <br /> Exporter,i certify that t o contents of this consignment conform to the lwme of the alladted EPAAdcawledgmmrl of Campt. <br /> I ceNfy drat to walk mbrirrtzallen stetement MuN ed in 40 CFR 262.27(e)(if I am a large quantity,ge (b)(11 a small quan*ganaralor)Is true. <br /> GanerarofsJo a Name Month Day Year <br /> OSk -c s-`�'ta-an9 I`L o f to <br /> ..0 16.International Shipments ❑import b U.S. ❑Expert kom U.S. Pat td entry w: <br /> Transpakr signature(for exports o*): Date leaving U.S.: <br /> IX 1T.TrartsWwAr#no+rl*msrtof RwApt ctMatedais <br /> aTransporter 1 Name Signadue Month Day Year <br /> $ N N <br /> yped Name • 5ignsture Month Day Year <br /> �s l <br /> 18.Discrepancy <br /> lea.Disaepam:y kxBcation Space Q Ouantty E Type ❑Residue ❑Partial Rejection ❑Ful ReJed. <br /> Manifest Relemin Number. <br /> 1 Bb.Alternate Facility for Generator) U.S.EPA ID Number <br /> W Fadiys Phone: <br /> G <br /> 8c.Sngrrahxe of Aaenrale Factiy(or alor) Month Day Year <br /> S2 46.Hazardous Waste Report Management Method Cafes Qa.,codes for haranfous waste beaboeni,disposal,and recyddhrg systems) <br /> p 1. 2. g, TKI41 <br /> H141 hili 9141 9141 <br /> 20.Designated FecaBy Ovma or Opereior.Cadf ceton of rdcus mala Ws covered by Bre manifest oxcepf as notal In Item 16a <br /> Pant d ame hta 1Month Day Year <br /> I� <br /> EPA f-san_ZQ0-22(Rev.3.05) Previous edBions are OBWeba. <br /> DESIGNATED FACILITY TO d NATION STATE(IF REQUIRED) <br /> L/ 177 liiu4:r: ....... <br />