Laserfiche WebLink
Please print or Mm. (Form deskjned for use on elite (12-pPA) Wmiter) <br />I* <br />Form Auoroved. OMB No. 2050-0039 <br />LFA I-offn BRW& (Kev. 3-M) Frevious e(IMMS are obsolete. <br />UNIFORM KAZAMOUS 1. Generator ID Number , , --2- <br />—Pap 1 of <br />3. Effwp??gffifrw <br />14 <br />- rO nC u5I <br />4 5 JJKWASTEFEST <br />WMWC A L 7 083 <br />1 1 <br />5. GwwaWsName and e Address; (d Mment than maft address) <br />PAIAF IA -A TRUCI(fNG <br />b~ F, FRH40INIT, <br />��'FOGFJON— CA <br />Generatou's Phone-. <br />6. Transporter 1 Company NameU.S. <br />EPA ID Number <br />AC <br />PIFIC CIOW�il LACQUER <br />7. Transporter 2 Company Nam <br />U.S. EPA ID Number <br />8. Designated Facility Nam and Site Address <br />U.S. EPA ID Number <br />PACIFIC RlIOIJRCIJFIM`.COVERY <br />11, 5-0 L A P I f 0 a t VE) <br />LOS AN(IFIX.S, CA -WW� 73 <br />FacWs Phone; ( "- . � ) 4 9 9 114 S <br />ga. <br />9b. U.S. DOT Description (ncludirg Proper Shippkq Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Pam Group (If any)) <br />Quantity <br />WL/W <br />X <br />t -MWF- PAINT k[A-A A <br />I <br />IX <br />0 <br />DM <br />Uj <br />3. <br />4. <br />14 Special HandllrV Insbuctions and" Information <br />4hI ) AP# <br />ctv(jvF,s, <br />ER(4"' 91,0 <br />rRAWiPOR TER I PHONI- <br />15. GENERATOR' 'S CLRTMMN: I hereby declare that the contents of this conskgnment are fully and acardlely described above by the proper shipl*Q name, and are classilied, padkaged, <br />mer ed and labelediplacarded, and are in all respects in piuper condition for ftansport acDmft tD applicable International and national governmental regulations, If export shipment and I am the Primary <br />Exporter, I certify that the contents of this tonsillmnent conform to the term of the attached EPA AdTaxleMment of Consent <br />I cerfify that the waste MnMMabDn statement identified in 40 CFR 2&27(a) (d I am a larp quantity geramilo) or (b) (if I am a small quariffty generator) is true. <br />raWsIOffiaWs Printeffyped Nam Signature <br />Month Day Year <br />ff <br />-1 <br />I— <br />16. International Shipments E❑ import to U.S. FlExport from U.S. Port of entry/exit <br />M <br />Transporter silyudiiure (for exports "): Date leaving U.S.: <br />U W <br />17. Transport Admwiedgnat of Receipt of Materials <br />Transporter 1 R"9&Typed Silinature <br />Month Day Year <br />0 <br />L <br />co <br />7- <br />Transporter 2 PrintedlTyped Name <br />Month Day Year <br />--signatura <br />Discrepancy <br />I18. <br />1 Be. Dimepancy Indication Space F1 Quantity El Type FIRsidus <br />El PaM R*.Un <br />El Full Rejeo, <br />MaWest Reference Number <br />18b. Alternate Fadrdy (or Genera" <br />U.S. EPA ID Number <br />I <br />Faff" Phone - <br />0 <br />LU <br />18c. Signature ofAlternaleFly (or <br />Month Day Year <br />19. Hazen[= Waste Report Management Method Codes (Le, codes for hazaidous waste fteatmaK disposal, and mqdq system) <br />G <br />1. <br />2. <br />3. <br />Facility Owner or Operator CerIffication of receipt of hazardous materials covered by the mardiast except as noted in ftein 18a <br />yped <br />Month D" Yew <br />LFA I-offn BRW& (Kev. 3-M) Frevious e(IMMS are obsolete. <br />