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1 <br />I <br />'Chi : ,.'t -..! •� -1 <br />V 1 <br />63 <br />! 947579 <br />Pli'ase.print or type. (Forr11 designed for use on elite 112-nitrh) tvnpwntpr 1 <br />D -TSC. 00969.. &484: <br />47037 <br />C...... A.......,.eA. ORAQ xln on Sn nn7n . <br />LPA Form BIUU-22 (Kev.:I-Ub) Previous editions are obsolete. dESIGNATED FACILITY T NERATOR STATE (IF REQUIRED) <br />10585.0584 <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />2. Page 1 of <br />3. Eme gong Response Phone <br />Manifest Tracking Number <br />WASTE MANIFEST <br />c. <br />7 7) %72_26694. <br />005516742 JJ K <br />5. Generator's Name and Mailing Address Generators Site Address (it different than mailing address) <br />r <br />Rarget 01526 ?argot 01526 <br />280 Spreckels Avenue ` 288 Spreckels Avenue Attn: Phots Lab Ka <br />Gene' p etA 95336 11091823-9982 C CA 95336 (20911123-990 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />21st CEMWY ENVMM@R7jAL HAnGENM W REVAMLLO ICARIM110164012 f� <br />7. T71e2 Com anyEZLaf U S. EP�umber O <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />HURLIAGTOH ENIROMMAL, LLC. KEIT FACILITY- <br />ACILITY-28265 <br />2926577TH AY6[IUU SOUTH <br />Facility's Phonet.(m7f UA 98032 ( 253) 872-8036 WRM91281767 <br />ga <br />, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste,Codes <br />No. <br />Type <br />HM <br />Quantity <br />Wt.Nol. <br />1017.60 ®ASTB COHOSIBB LIQUIDS, D.O.S. (SULYURIC ACID, POTASSIE <br />062 <br />22 <br />791 <br />HYDRO%IDB) 8 PGII <br />00 <br />OF <br />00 570 <br />2. <br />UA 2' <br />3. n <br />o <br />4. <br />14. Special Handling Instructions and Additional Information P <br />III -'aODAI k 06 - UBG054) PLASTIC CONAIRERS(i3M PBOPIM PP8 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: 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 />marked and labeled/placarded, and are in all respects in proper condition for transport according to appficable international and national governmental regutatlons. 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 EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity gene or (b) (if I am a small quantity generator) is true. <br />GeneratoeslOffemes Printedfry d Name Signature `- Month Day Year <br />4ACI t6o S E 0q II a c1 9 <br />J16. <br />1- <br />Intemational Shipments <br />❑ Import to U.S. ❑ Export froPort entry exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17: Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printedfryped Name Signature Month Day Year <br />IL <br />N �l� �/ 04 to a <br />Z <br />Transporter 2 Printedfryped Name i Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Ouantity ❑ Type Residue ❑ Partial Rejection ❑ Full Rejection <br />I` <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />t.1 <br />LL <br />Fadktys Phone: <br />w <br />18c. Signature of Altemate Facility (or Generator) <br />Month Day Year <br />Q <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />�rPnnl,; <br />1�i"f' <br />2. <br />3. <br />4. (� <br />d Facility Owne <br />or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Signature fvlo <br />� <br />pp <br />Day_ Year <br />" <br />1ofi <br />LPA Form BIUU-22 (Kev.:I-Ub) Previous editions are obsolete. dESIGNATED FACILITY T NERATOR STATE (IF REQUIRED) <br />10585.0584 <br />