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dI111nIIIIiIN�iNIIf�I�il��illl�ll�lllllN �N <br /> Please gNtt or type.(Form designed for use on eMe(12-pildf)typewriter.) Form Approved.OMB No.2050-w39 <br /> UNIFORM HAZARDOUS 1.Generator ID Nun bar 2.Page 1 of 3.E Response ro4.Me rackiqNumber <br /> WASTE MANIFEST 111L1118659111L1118659 2 An 0)326-1221 044265441 WAS <br /> s. ORP. / DAWN JESS K <br /> 3333 BEVERLY ROAD 2180 E. MARIPOSA RD. <br /> HOFFMAN ESTATES IL 60179 STOCKTON CA 95205 <br /> (209)W-6205 GEN: 11782 <br /> Generalols Phare: <br /> US,EPA ID Number <br /> HERITAGE TRANSPORT, LLC 1 SIGNAL HILL IND058484114 <br /> 7.TrarmporW 2 Name U S.EPA tO NunDer <br /> f� ,-4.1 f a -/- aka 98i - If 7IF/ <br /> s. NTAL SERVICES LLC US.EPA ID Number <br /> 284 E STOREY RD AZDO81705402 <br /> COOLIDGE, AZ 85228 <br /> (520)723-4167 <br /> F � a Phone: <br /> 9a. 9b.U.S.DOT Description(lnduding Proper Shipping Name,Hazard Class,ID Number. 10.C ntaners 11.Taal 12 UrA <br /> HM ane PackN Group(e any)) No. Type Qum" Mtvot 13.waste Codes <br /> X 1 RQ UN1950,WASTE AEROSOLS,2. 1, (D001 DO39), 331 D001 D035 <br /> ERG#IL6 <br /> o <br /> 6r—F.,4 I CF P D03 <br /> Z X 2. RQ,UN1978,WASTE PROPANE,2. 1, D001),ERG#11533I D001 <br /> 3. <br /> S� r s C lO <br /> C Inao+e+— P�lw <br /> s <br /> 4 <br /> X 4RQ UN1993 WASTE FLAMMABLE LIQUIDS, N.0.S. , D001 .11y3,PGI1, (PAIN), (D001),ERG#I2r.8 <br /> )CFx2F5 C o� <br /> 14.1sp .It2432584 lLDR _ 92 4.1412_0451)303 LDR <br /> hF2o�1 �cy� +► �I4.r.�/ <br /> 3crr 3><q I XCY3 113092237G <br /> is. GENERATOR'SIOFFEROR'S CERTWICATTON: I hereby,declare nay tits conwft offt eonsignmW are run,and accureeely described above by%proper shipping name,aro are daronled,padraged. <br /> marked and lebaledrpteranied,and am In as respects OR"ca460n for transport acoof*q b appkable internaeorw and national govemmenu requiaeone.If export <br /> Exporter.I cw*tial ftoonWrls of Ihq coneigmlent omfam to the larvas of to abched EPA AdalvwwVnent of Consent sMpn ant am I am u Primary <br /> I WWY that ft wears ro"Mi2abon slatemera identified in 40 CFR 262.27(a)(d I am a large quantity generator or(b)(d I am a small Brans y generator)n we. <br /> yer <br /> 16. <br /> Import to U.S. ❑Exp rl from DS Pon of -- <br /> T Dab U.S.: <br /> W 17 Transporter Advpwledgment of Receipt d Materials <br /> 1 <br /> ype1 Month Day Yaw <br /> d7. 2 Pr4ged/Typio Nems <br /> - --yV - ------- <br /> 16a.Discrepancy ❑ 0uan"', [IT" ❑Reswue ❑Patial Rejection ❑FA Rejection <br /> Manifest Relereoce Number <br /> 18b.Alternate Fadery(or Generabr) U.S.EPA ID Number <br /> U <br /> Q <br /> LF- — s Ptr— <br /> ` 16e.Sgmaere AWamaw Fadfly(or tar) Month Day Year <br /> 2 <br /> Q <br /> 19.Ha7adow waste Repod Management Method Codes(i.e..oodeS for Imzardous wash tnsabrient,daposat and recyclsrg systems) <br /> UJ <br /> 1 <br /> H141 2 H141 3 �}#-41-- 4 H141 <br /> 20.Deslgnabd Faddy Owner or Operator Caruftaoon of receipt of raza*m materials covered by the mandest except as rated in Mm 1 Ba <br /> Pnn yped Nameraaue Ye <br /> Month Day ar <br /> EPA Form 87pp 22(R .3-M Previous edtions are obso DES NATED FACILITY TO DESTINA STATE(IF REQUIRED) <br />