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1M.C. 04-0. 18S3 <br />Please print or Mm. (Form desbvW for use on elite (12-ottch) ftemiter.) <br />Form Approved. OMS No. 2050 -OM <br />EPA Form WUU--M% -10) ftvious editions are obsolete. I DESIGNATED FACILITY TO DESTIOTION STATE 1 IF REQUIRED) <br />12637.2236 <br />umFoRmHAzARDous [GeneratorlDNmber <br />CAR ID <br />tergency Response Phone <br />14. Maid — TraftV NumberWAM JJ <br />MANIFEST <br />S."01AtMe"MANORM-100 <br />P.O. BOX 20243 <br />P140ENIX AZ <br />05038 <br />SCOSDO2200 <br />GeneraWs Phone; <br />"WROY99MMENTAL SERVICES <br />U.S. <br />.EM3866794 <br />7. Transporter 2 Company Name <br />U.S. EPA 10 Number <br />S. ry Address <br />U.S. E&SM9019 <br />1630 WEST 17 Tri EET' <br />LONG BEACH CA <br />90813 <br />BOD -827-6729 <br />FadWsPhwe: <br />9S. <br />2b. U.S. DOT Description (includim Proper Shipping Name. Hasan! Class, 10 Numbe, <br />loxontainers <br />It. Total <br />12. Unit <br />13. Waste Codes <br />NO. <br />Type <br />HM <br />and Pacldq Group (if any)) <br />QUM* <br />WUN. <br />I•WN RCRA MAZARVOL15 WASTE LIQUID <br />HYDROCARBM) <br />(WATER WIM TRACE <br />001 <br />DM <br />G <br />331 <br />-SOLID <br />2. PION RCRA HAZARDOUS WANT <br />(DIESEL CONTAMNATED DEBRIS <br />3S2 <br />Atn <br />UVI <br />DM <br />200 <br />P <br />3. <br />AE1 <br />1V too u <br />4. <br />%VM MW ons %M Z -V161 <br />PROFILE#1 )100522 2)10D523 <br />15. C4MRATOR'SIMEROWSCMIFICAMON: I hereby declare that the contents of this consoment we My and e=rM* daubed above by the proper shipping mune. and we classified. pdm*. <br />madad and labeledWowded, and we in all respects In proper condition for transport acowft to applicable International and national governmented regulations. If export shipment and I am the Primary <br />kkftcwftibdft onsignment conlon to the terms of the attached EMAdmowledlimentof C4nsent <br />"Is ""nent co�, <br />40 CFR 262.27(a) (N I am a [Me quen*gwwatoor(b)Oflamasmdquandty <br />efgt��- �� generator) true. <br />I em*c),* <br />Mat <br />pi <br />15. International Shipments ElImport tou.s. <br />❑ Export hm, U.S. Port Of entry/we <br />T -M -W soan (or exports Miy): <br />Date Waving U.S.: <br />17. TransporterAftow%dliment of Recut of Materials <br />Transporter I PrinteCyped Name <br />S <br />moo Day YM <br />Mo., 0*4td <br />2 131 1 6-7 <br />Transporter;! P*ftdffyW ftme <br />Swiftne <br />Morm C" Year <br />I& !Discrepancy, <br />118a. Dftmpxuy Indication Space El 0"'My, <br />13 TM ❑Rosldw <br />Moft Reference Number. <br />El Partial Rejection ❑ Full Refection <br />18b. Afternste FSCW (or Ciamere" <br />U.S. EPA ID Number <br />Fed" ftm- <br />I raw my (o f M 0 =nft <br />Day, Yew <br />19 HtWftw Waft Report Manallement Method Codes (i e., codes for hwtardotm waste treatment, ftposal, and recyc" systems) <br />12.3. <br />1 <br />4. <br />20. Desilinsted F _ Oww or Operator CeMbdon of receipt of hawr&A covered by the manifest except as noted In !tern Ift <br />PrintediTypedTt- <br />SWAM <br />d2=:==h— I i1to I MI <br />EPA Form WUU--M% -10) ftvious editions are obsolete. I DESIGNATED FACILITY TO DESTIOTION STATE 1 IF REQUIRED) <br />12637.2236 <br />