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Tease print or type.(Farm designed for use on elite(12-pitch)typewriter.) <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS <br /> 1.Generator ID Number 2.Page t of 3.Emergency Response Phone 4.Manifest Tracking Numher I' <br /> WASTE MANIFEST CAL000331425 � 800-633-8253 017087630 J J K <br /> 5.Generators Name and Mailing Address y6er DC118811R17h Generator's Site Address{if different than mailing address) <br /> Kelly Moore Paint Ca�mpany `.hint Company <br /> 987 Commewas suvo ' g <br /> San Cw1w,CA94070 Tracy, 976 <br /> Generator's Phone: 209-833-7494 <br /> U.S.EPA ID Number <br /> 6.Transporter 1 Company Name C ROW179747 <br /> inQeftium (Sacmm4into)&""'1=RI PHONE-CuSt iD#8788-t1t W**" <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name CAD982523433 <br /> Dillard Environmental Setnldces <br /> 8.Desi Hated FacilityName and Site Address U.S.EPA ID Number <br /> 8n=nta En%ftnmenilal Sotkftionw LLC MR000127621 <br /> 58.25 Old Porter Rd <br /> Pottage,IN 46388 ' <br /> Facility's Phone: 219-713-5484 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID,Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Ncl. <br /> 1.Non-RCRA I Waste s quid Galax paint) 331 <br /> ' s�. � <br /> wl _..., <br /> C <br /> I <br /> 3. <br /> r <br /> i <br /> 4 r <br /> i r I <br /> 14.Special Handling Instructions and Additional information <br /> Document D48979 Sds Order 65314 <br /> 1)Pmfte#41466732 DOT ERG# <br /> 15. GENERATOR'VOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classed,packaged, <br /> marked and iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAA(,knowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator}is true. Month Day Year <br /> Generjorsiofferors Printad{Typed Nfl 1111-7 <br /> am� Signatu <br /> 16.Ince atienal Shi meats ❑import to U.S. ❑Export from U.S. Port of ontrylexi: <br /> Date leaving leaving U.S.: <br /> -- Transporter signature(for exports only): <br /> tY 17.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> Month Day <br /> Signature Year <br /> TrapSporter 1 Printedfryped Name <br /> a d �, f <br /> j' <br /> Signature Month Day Year <br /> Q Transp er Printed/Typed Name "? I <br /> 7 <br /> i 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceLl Quantity Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> ❑ <br /> Manifest Reference Number: <br /> � U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> t= <br /> 6) <br /> .4Facility's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> a <br /> z <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposai,and recycling systems) <br /> 1. ? 2 <br /> 3. <br /> 20,Designated Facility Owner or Operator:Germcation of ceip of hazardous materials covered by the manifest except as noted in Item 18a L�\ Mo Day Year <br /> Printedpia <br /> Q <br /> get _.�lfyp Signature <br /> t L f <br /> EPA Form 8700-22(Rev.3-06) Previous editions are o solete. DESIGNATED FACILITY'T GENERATOR <br />