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T F39E8Bti4 1% (�fJ -17 `/ 7'`y G' 292U 4V <br /> Please print or type.(Form designed fo use ors efste(12-pitch)("writer.l F Approved.OMB No.2053.0039 <br /> UNIFORM HAXARDOtE5 1 Ganeralor ID Numhef 2 Pate 1 of 3.Emergency R¢spanse qhe^s a.Manifest irackIn umber <br /> WASTE MANIFEST ( flLtliDIJ391Qt10 (B77) 577—z�fl� OD Q 3057 DAT <br /> 5 Genarator's Name and Ma l'rg Address Generators Sne Add-ss(d Mereol dam maiprg <br /> IN t0T5 S10RE5 BIG LOTS MD5 <br /> 706 PHILLIP RD Atria: SERA FERARV 11161 NEST LAW <br /> GeneratoesPhorre C()f.Lmus OR 43779 (6111270-01" STDCK10R CA 95210 <br /> 6 Transpwar 1 CanpanyName U.S EPA 10Nwriber <br /> G rERICYCLE SPECIALTY WASTE SOLUTIONS INC MNSODOIID 24 <br /> I Transporter 2 Ccmpany Name U.S EPA ID Number <br /> 8,llesigneled Facf`t�lr- <br /> 7151 <br /> CFJ4i1IRY EWIRDNIIFNTAL MANNEYOR OF t?EVRDA, LE C <br /> 2645 Rulands Drive East <br /> FaciikysPhooe: FTWY NV 14418 (1751 S75-17b6 NYD9$D$9 338 <br /> ga. °b.U.S.DOT Doscryrt an Cinoudin Proper Sh'ppmg Name,Hazard Class,ID Number, Ip.Containers 11.Tclat 17.Urrit <br /> Jim and Packing Group(if any)) 73.tKasle Cedes <br /> Ne. T pe Quantity VljVV. <br /> 1. UNI159 (BASTE MEOWS 2.1 Ci60801=10811 331 0601 <br /> F <br /> 5 <br /> x (Subwfe. Re. , 1 <br /> x _ rg) <br /> 4• UN1993 MSTE FLAFI MLE LIQUIDS, R.Q.S. (KEROSENE, DIES 1 3 PGIT 331 <br /> X R6(D601=116► 35" P <br /> 14,Spedal Handling Instructions andArIckional Information , <br /> (1) IILLREWDSOL5-63 - ERG(1261 RER050L5 _ 1-11611"i fiftlye CORRMVE tic (34i <br /> GeRRI)SW MV (41 ILFLWID-63 - MUM FLI'tI VLE LIOIiM <br /> 15. GENERATORWOFFEROR1 CERTIFICATION:I hereby Cedare dtaf the contents of INs onrsignmard are fully and a=rwj*described abc'm by the proper shipping narne,and are rkassifiod,packaged. <br /> marked and lebeieo6placasded,and are In all rosW%in propor pondiyon ku aansport according to applzabla ialernaliDrWand naEonal govamrremal feguiarws.Ifezport sh pmen(and i am the Prmary <br /> Expodw,,I Gently rhaphe contents al this corsgnmenl rcnlo rn to the teems of the atlached Mftnowledgmertt of Consent. <br /> 1004 that the waste m'raimiz&m slalemenl identbud in 40 CFR 26227(a)(it 1 am a large quantify,generala:)or(b)(d t am a snob;uantiEy generaior)is he. <br /> Generator rs P y Srt�na F-1 L arlh Day <br /> .1 16.rnb ntalion Shipments <br /> T— ._ impru!to U S. L.-J EMPor1 from U.S. Port d ertfryluxil:—_-- <br /> Transporter signature(for evorts onty): — - '- <br /> - Dale leaving U.5 <br /> 17 TranWrlerAdmowtedgmenl91Receip;ofMaterials <br /> LU <br /> Transporter 1 Printadlfyped Nam S gnah re W,rMlh Day Year <br /> _ <br /> Q 'lia.sporler 2 P lodflyped Name ! Signatwe Al mb Day Year <br /> t8.Discreparxy {{� I��}} <br /> 180.Discrepancy Irtluahon Space Quant ly LI Type ❑Residue LJ Parliat Reiecuon ❑Ftr!Rqw oro <br /> Manifest Relaarrce Nwnber. <br /> 1$b,Alternate Facility(or Generator) U.S.EPA e)Nurrrber <br /> a <br /> u <br /> 4 <br /> �- FJtrEily's Phone' <br /> 18c.Signature of Allemala Fac lily(or Generator) Monih uay Year <br /> a <br /> ri719.Hazardous Wasia Report Marogw."N Method Codes it e..codes for hazardouwaste treatmet,a saland re Ycin9 s stams) <br /> 0 1. 4. <br /> ILI <br /> 20 Designated Facll.fy Owner or Operator:Cerl-ficawn of eco pl of hazardous maler als covered by the manifest exMpt 0,5 Wed In Item 18a <br /> PrnlcdlTypadName% gnature \ kloips Day ear <br /> { f J ( 6' <br /> EPA Form 8706-22(Rey.3 05) Previous editlonsare obsotete. DESIGNATED FACILITY TO DESTINATION TATE(IF REQUIRED) <br />