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FROM : L.F.W. MFG. INC. FAX NO. : 209 465 6521 Feb. 16 2007 11:53AM P7 <br />Please print or type (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 20.50-0039 <br />4 .i vI'll .- r,.—. v -ver DESIGNATED FACILITY To DESTINATION STATE (IF REQUIRED) <br />1 Gtnefator lD Numbtr 2. Page 1 of a, Emergency Response Phone 4. Manifest Tracking Number <br />EST G t .33f�(r 001827333 JJ <br />FUNIFORMRDOIlS <br />and Mailing Address Generators Site Address (if different than mailing; address) <br />Gen tors hone: <br />6. Transporter 1 Company Name U.S. EPA 10 Number <br />1i@i>�l�+ RS[ti 'tSpFtllCes, A " '1 <br />7; 4tanggarter'2 Company Name U.S. EPA ID Number <br />a, Designated Facilley ane and Seta Ad'drass , U.S. EPA tD Number <br />Facility's Phone: <br />ga. 9b- U.S. DoT Description (including Proper Shipping Name, Harare Class, ID Number, 10. Containers 11. Tptal 12. Unit 13, Wasle Code$ <br />HM and Packing Group (If any)) No, (jpe Quantity Wi.Afot. <br />-30 <br />Uj <br />t9 <br />3. <br />4, <br />14. Spedst Handling instructionsstand Additionai information <br />' <br />00� <br />15. OEW-R ATOR'S10FFEROR'S CERTIFICATtONt I hereby declare that the contents of this consignment are fully and accurately described above by the proper Shipping name, and are classified, packaged, <br />rt kod and Wbeledlplaearded, and aro in all respects in proper condition for transport according to apolicabie tntemaUonal and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the -contents of this consignment conform ib the terms of the attached EPAAcknowtedgment of Consent. <br />I certify that the waste minimizaEon statement identified in 40 CFR 262.27(1) (k t am a large quantity generator) or (h) (if I a small quan " generator) is true. <br />Generators/Offerors PrintedlTyawftme Signature Month Day Year <br />2A <br />11 <br />16. International Shipments LJ import to U.3. ❑ Export from U.S. Part of entry/exit: <br />Transporbrsoahrre (for exports only); Date leaving U'S': <br />U= <br />17. T=% -,j orter mem of Receipt of Materials <br />Transporter lPtin Name Signature Month Day Year <br />O/ <br />aJE <br />(G� a <br />TransporW Priniad/Typed Nam S' aturo Month Day YeAr <br />M <br />1- Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partiai Rejection ❑ Full Rajecti0n <br />Manifest Reference Number. <br />18b. Alternate facility (ar Generator? U.S. BPA IR Number <br />J <br />U <br />Facility s Phoma: <br />Q <br />98c. mature oEAttemata N (or GCr,4rdtOr) Month Day Yeas <br />1g. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />4, <br />20, Deet Hated Facility Owner or Operator: CerGrx stfon of receipt of habardous materials coveted by the manifest except ns nand in Itarn 1 Ra <br />Pnntednyped Name Signature Month Doy oar <br />4 .i vI'll .- r,.—. v -ver DESIGNATED FACILITY To DESTINATION STATE (IF REQUIRED) <br />