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Please print or hroe. (Form clegianedfor use on elite ;(I2-01(ch) iter.) Foran; . OMB No. 2050-0039 <br />EPATom18700-22 (Rev, "5) Previous editions are OWde. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 11.6onerartorlukumber <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone4. <br />tTraddn Number <br />014 0 g57764 JJ <br />WASTE M"IFEST CAD 9 8 2 3 4 8 9 3 0 <br />(800) 424-9300 <br />e: GenAm <br />N1 MCCUTCH IMC s (8 ) <br />12S W SONORA STREET <br />STOCKTON CA 95203 <br />209 466.9704 <br />GonendoesPhonw. <br />B.T 1' U.S.EPAID Number <br />ASBURTENMRONMENTAL SERVICES C A D 0 2 8 2 7 7 0 3 6 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />r <br />8, Designated F Name and Site Address U.S. EPA ID Number <br />!*1tOQ#1 WATER TECHNOLOGIES LLC <br />5375 SOUTH BOYLE AVENUE <br />LOS ANGELES CA 90058 CAD 0 9 7 0 3 0 9 9 3 <br />FwWs Phone: (323)277-1500 <br />98. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13, Waste Codes <br />No. <br />TWO <br />HM <br />and Packing Group Of any)) <br />Quantity <br />W1.1vol. <br />I. NON-RCRA HAZARDOUS WASTE, SOLID (METAL <br />181 <br />o <br />GRINDINGS/DIRT/DUST) <br />I <br />-!, <br />D <br />P <br />2. - S WASTE, SOLID 0 HFILTERS) <br />352 <br />D <br />P <br />4, <br />14, Spufal HsI <br />EMERGENCY CONTACT : CHEMTREC 1-800.424-9300 NAERG# 9B1 :171, 9132: 171 * PROFILE # 9B1; AP203469 MEA <br />GRINDINGS, DIRT, DUST, 9B2: AP203524 PAINT BOOTH FILTERS * P500 026262 *APP RIATE PERSONAL PROTECTIVE <br />EQUIPMENT &' <br />15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratelydescribed by the proper W*pkrg name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper comf don for transport according to applicable IntemsUonai and national governmental regulations. Y export shipment and I am the Primary <br />Exporter, I certily that the contents of this consignment conform to the terms of the attached EPAAcknowledgm ent of Consent, <br />I cor5fy that the waste minimization statement kientifled! In 40 CFR 28227(a) (I i am a large quatft geruuator) or (b) Of I am a small cilLenifty is true. <br />a PrintedtrypedMonth Day Year <br />�v i3 1 <br />J <br />1 . Irate trona) Shi ❑ Import to U.S. ❑ Export from U.S. Port �✓ <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />� <br />T tem Sionsh" Month Day year <br /># <br />Transports?2 PfintedrrypedName Signature Month Day Year <br />18. Discrepancy <br />18a, DWxepanq7t Indication Quan�ty ❑ T,� � ❑ Partial Rejection El Full Ref ectlon <br />e I li �1twt~r ef- c. lElo14 V V-1- no tl 1 ric.. <br />MaMfast Reference Numb <br />18b. ANemate Facility (or Generator) )?� � � � U.S. EPA ID Number <br />V <br />LL <br />Facility's Phone: EN�i.fl ' T <br />W <br />18c. Slgnature of Alternate Facility (or Generator) /^ i onth ay ear <br />JFR�: <br />19. Hazardous Waste Report Management Method Codes Q.e., codes for hazanfots waste treatment disposal, and recycling systems) <br />® <br />1. 2 <br />20. grated Faetitiy Owner or Operator: Certificationof receipt of h ous materials covered by the manifest except as r>� In Item 1l1a <br />swan Month— Year <br />EPATom18700-22 (Rev, "5) Previous editions are OWde. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />