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2 <br /> 8042 <br /> se print or type.{Form designed for use on elite{12Titch)typewriter.) Form App:.'a c OMB No-2054-009 <br /> UNIFORM HAZARDOUS WASTE MANIFEST 21.Gene,;tor lD Number 22.Page 23.Msntlest Tracking dumber , <br /> (Continuawn Sheets CAL00039LO69 10f L2901DAT <br /> 24.Generator's Nara <br /> 1I6 LOTS STORES <br /> 39A PHILLIP RD RTTH: GENA FERRRU COLE IUS OH 43329 ( 141229-4614 <br /> 25-Trarsporler Company Name, U.S_EPA ID Humbm <br /> 26.Transporter Company Nome U.S.EPA ID Number <br /> 27s. 27b_D.S.OOT Dmatifion(notudrrrg Proper Shipping Name,Hazard Class,ID Number, 28.Caniaham <br /> 29.total 30.Unil <br /> NAI and Padang Group(d any)) No. Type MAA 31.waste Codes <br /> S 091.993 VASTE FLA #L.E LINDS, H.O.S. (KEROSENE, DIESELI 3 <br /> x PGII R00491=199) p <br /> I1RO . 11918 � - <br /> , � N- 390 <br /> 1 , <br /> n $ HIHS VAM OffiffiN Skit, <br /> , <br /> x # <br /> 4�3-.feI 6F!f4 l4Arirb4e i <br /> 1EN2111 VASTE TOXIC, LIQ BS$ ORMC, I.O.S. (2,4-1) L,I P611 � 3311 BOI# <br /> x <br /> 446 UNWQ WIPE fff.x <br /> EENT) <br /> 14 , <br /> 32 Spelt HaCOM Nish a ions and Miditional Infarmatioo <br /> 4) ILTOXIC-03 - ER64' S3) TOXIC <br /> LIQUIDS LOOSEI' ! --69 � <br /> 33.Transporter AdoiaMad rune of Receipt of Maw <br /> F6ntedliy*Narrre Signature Me* Day Year <br /> 34.Transporter Adm of Reosgrl of mammy <br /> Pftdrry*Name 5igrrature Month Day Year <br /> 35.Dgnpancy <br /> .:t <br /> Ld <br /> w , <br /> a <br /> F- 36.Herafiiaus 4Yaste Reporl Managetrwd McHiad Codes(La.,mbs for hazardous arae treatment.di al,W reit*g ) <br /> LU <br /> # 18) t I2) (1 <br /> EPA Font 8700-72A(Rev.U5) Reworps f d tarts ere obsolete. DESIGNATED FACILITY TO DESTINATION STATE OF REQUIRED) <br />