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ASEEII�R�11�l1f <br /> m w sI Milli 1111111111111111111111111111111111111IIIIIIIIIIIINillllll� <br /> Please print or type.(Form designed for use on elite(12-pft)ii -- Form <br /> Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Ilertifeet Tradt <br /> WASTE MANIFEST CALO)0018659 (800)326-1-21 1 1 1 RCS` <br /> RP. / DAWN JESS { <br /> 1KAA�ATIL 60179 �KFTON ' 9c0� <br /> (209) 46-8205 GEN: 117582 <br /> Genera6oIs Phone: <br /> ' SPORT, LLC us) tt9V134114 <br /> 7.Transporter 2 Company Name US FPA ID Number <br /> e. R®fiNEN'MROMVeNTAL SERVICES LLC U.S.EPA 0 Number <br /> 7901 WEST MORRIS STREET IND09-21901=' <br /> INDIANAPOLIS IN 46231 ` <br /> (317)243-0811 <br /> fadlitys Phone: <br /> 98 1 9b.U.S.DOT Description(including Proper Si Name,Hazard Gass,ID Number, 10.Containers <br /> HM and Packing Group(d any)) 1 t Total 12 Unit No. Type C 13.Waste Codes <br /> uantrry Wt_Nd. <br /> X II <br /> RQ IJN1950,WASTE AEROSOLS,2. 1, (DO01 D039), 3J1 DOO1 035 <br /> o ERr,#1 M6 I �+ <br /> W <br /> Z-p -P6039 <br /> X z. RQ,UN1978,WASTE PROPANE,2. 1, (D001),ERG#115 331 D001 <br /> ( i f 1)F-'I(-)- F-� L�'z F I I1 <br /> X 3. RQ UN1993 WASTE FLAMMABLE LIQUIDS, N.0.S., DOt)1 'A� <br /> 3,PGI1' (PAIN'), (D001 t,ERGCp#128 Cj" �� D <br /> X ° RQ ASTE OXIDIZING T 141 D001 <br /> 5, 1 PMI (HY ROGEN PEROXIDE SODIUM <br /> HWCHLIDA I TE), (DO01),ERG#146 ( Ii Or)c <br /> Of <br /> IVVI al ', '19.8'l 4'6465647_LDR 3.W12 0465645 LDR 4.W9_Q465642_LDR <br /> a =1 pi-z C � 4 (,A- —I <br /> tIk`'yc-yl'nd°� 1 -i 5-y [1172477]6 <br /> 15. GENERATOWStOFFEROR'S CERTIFICATION: I hereby declare Ctat the contents of this consgrnerd are fully and aocura"described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are mall respects in proper eonci for Yanspcu(according to applicable international and naborW 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 ahadned EPA Aak noMedgment of Consent <br /> I certify that the waste minimization staternent idenitfiedin 40 CFR 262.27(a)Cd I am a lenge quantity generator)or(b)(ii I sma ua eneramr)i&true. <br /> 7s ypV Name . ay ear <br /> 4 <br /> j 16.International Shipments <br /> Z ❑.port b U.S- ❑Export from U.S. Port of entrylexit <br /> Transporter signature for exports CNy). Uale leaving U.S.: <br /> 17.Tran4wter Aciugwledgment of Receipt of Materials <br /> rrPrintSignature n ay Year <br /> O <br /> a �i4 I <br /> / s9 <br /> p. <br /> ur <br /> Q Transporter 2 Prin ped Name natu. <br /> Month ay ear <br /> 18.Discrepancy <br /> 18a.Disotepancy Irdication Space ❑ Quantity ❑Typa ❑Residue Panrel Refect xn FuRejecion <br /> Manifest Reference Number: <br /> 18b.Alternate Facrity(or Genera(or) US EPA ID Number <br /> J <br /> U <br /> d <br /> r+- FacBi 's Phone <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> z <br /> 19.Hazardous Waste Report Management Method Cortes(i.e.,codes Iii hazardous waste treatmern,tl sposal,and recyc;irg systems) <br /> 1 H141 H14 3 H14 4 H141 't <br /> 20.Design Facility Owner or Operator Certifir d wee of hazardous materials co by the mamfes.excej as ed in Item 1 <br /> PriVedrT Na Slonasure Month Day year <br /> ]1.,7f1j" 14 X, 1 b <br /> EPA Fo 2(Rev.3-05) Pre s are oosdete ED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />