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r �: —. IIlIIH11111 nN11117u1111N1HntIRE 1ttlmm�ll1mm rMll <br /> Pleaseprint or type. Form ned for use on elite(I2-pitch) Formed.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS i.Generalor D Number 2.Page 1 of 3.Emerganq Reap"Phare 4.lMaMiest Tradchp obt," <br /> WASTE MANIFEST CAL000018659 2 (800)326-12221 <br /> s. WVVbEMRP. / DAWN JESS <br /> 3333 BEVERLY ROAD 2180 E. MARIPOSA RD. <br /> HOFFMAN ESTATES IL 60179 STOCKTON CA 95205 <br /> Gerterehr'a Phone: (209)448-8205 GEN: 117582 <br /> " U.S.EPA 10 Number <br /> HERITAGE TRANSPORT, LLC IND058484114 <br /> 9� —Fi ^ � U.S.EPA ID 5& <br /> F 1' Nemetand 1' •/� 11 U.S.EPA 10 Number 1( <br /> AG ENVIRONMENTAL SERVICES LLC <br /> 7901 WEST MORRIS STREET IND093219012 <br /> INDIANAPOLIS, IN 46231 <br /> .. <br /> Fs (317)243-0811 <br /> 9a. I 9b.U.S.DOT Deaaipem(Indud}g Proper SNpping Name,Hazed Class,ID Number, 10.Confawws 11.Taal 12.Una <br /> HIM enc Pig Group(t-Y)) No. Type Quantity WUlthbl. 13.Waste Codes <br /> 1. <br /> w- X RQ UN 1950,WASTE AEROSOLS,2. 1, (D001 D039), 1 r c 331 D01)1 035 <br /> o ERfj'#12rl 1.1' <br /> 1 F D039 <br /> z 2. <br /> aX , , , , C1 1 <br /> X 3. RD UN1993 WASTE FLAMMABLE LIQUIDS, N.O.S., D D001 _ <br /> 3,PGII, (PAINY), (D001),ERG#128 CF <br /> i <br /> X 4 , M.S. �S �r _ <br /> 14. I Harrill Iristrx"s and Additional 1 - I <br /> 1,W8_G?46 544_LDR 3,W12 0466560_LDR 4 '19-94r <br /> AEpo I 7/116e ruNM 9/ok <br /> 11194242)G <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of{}tors consrgnmenl aro fully 0-M aauatety above Ube proper vTwv name,and are dassified,packaged, <br /> marked and latMedlptaarded,and are m all respects 4r proper condtion for transport according to applicable international tions"govern r Is.N export shipment and 1 am the Primary <br /> Exporter,I certify brat the cordents of tiers consignment conform to Me teras of Ure attadbed EPAAckwMedcjnaH of <br /> I certify Ural Bre waste mmyrzation slatemeo Identified In 40 CFR 262.27(a)011 am a large quantity gerwator)or(b)(d tAn a small quarrkty Is true. <br /> 5 Prip arae lTonT Year <br /> i477 4 <br /> -1 Shipftien <br /> T ❑ to us. El Export from U.S. entryIWA.. <br /> ? Transportw )r owls Date leaving U.S.: <br /> ,a 17.Transpaler Acknowledgment of Receipt of Matenah <br /> F' <br /> Transpol 1 P'iedffyped Name 39natum Month Day Yw– <br /> Transportell2filni"T b9imure Month Llay Year <br /> 18.Discrepancy r 1 <br /> 18a.Disrrepancy kdwbon Space ❑Q ty ❑Type ❑Residue U Partial Rejection ❑Ful Rejection <br /> Marcfest ReNrerce Number: <br /> 18b,Alternale Fatty(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Q <br /> �+- <br /> Facility's Phone: <br /> Q 182.Signahue d Alternate Faafify(or Generator) Month Day Year <br /> N19.Hazardous Waste Report Management Method Caries(i.e.,codes for hazardous waste treatment,disposal,and recydkN systems) <br /> w <br /> 1 2 <br /> H141 H141 3 H141 H141 <br /> 20.Designated Fadbty Owner of Operator:CerbficaWn of receipt of hazardous matenals covered by am manifest a as nded in Item 18a <br /> Prri edfTyped Nam Signature I Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATE FACILITY TO DESTINATION STATE(IF REQUIRED) <br />