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Please print or type.(Ford6signed for use on elite(12-pitch)typewriter.). Fgrrp proved.OMB No.2Q5Q-0039 <br /> UNIFORM HAZARDOUS 1 Gape <br /> gore H b y 2.Pa 1 of 3 Phone•M 4.Manifest Tracking Number <br /> �, 0 �4 -2 4 a 1 � � ��-� D17�.�.63�'5 �l�lK <br /> WASTE MANIFEST <br /> a 5.GoLrer'MMIIOpij; BHT LINE INC. Gm; 11 <br /> 5D0 OLD DOMINION WAY 601 DARCY PARKWAY <br /> THOMASVILLE NC 27360. L.ATHROP CA 95330 <br /> 336 8225760 <br /> Generator's <br /> d�Phone: <br /> emn� ��m� <br /> @ 6.TrFrSM& LTfV� ffiental S('.roces U.bEPAID,Ajurr&,5 3 8 6 B 7 9 a <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> s:n�Q��girtrsjr�tgrass U.S.EPA ID Number <br /> 1630 WEST 17TH STREET <br /> LCNC-r-BEACH CA 90813 <br /> 800 827-6729 C A D 0 2 8 4 0 9 0-1 9 <br /> Facility's Phone: <br /> ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 1 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Ouantity WtNoI. <br /> t1C 1 .PGIII <br /> om <br /> z 2. <br /> or <br /> t�.o P <br /> 3 q I 6 111 U FSI]' ' <br /> 4 <br /> 4{ t .,P i <br /> F <br /> �. -s Hair r q or nd91 O01f + ]8 00680 {PETROCHEM PO H35G45-18] l l LP5}t�4 -43 <br /> [��'1�(�i� ��'�� SKS` 1..�5 ►��[? -�3 1. �.�, i.x►�r. E��a�• <br /> �X?a 12--0. 10'C'o o) NOIZO <br /> 15, GENERATORVOFFEROR'S CERTIFICATION: I hereby declare that the contents of this cons[nment are fully and accurately described above by the proper shipping name,ar4are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in ptopercondition for transport according to applicable intemat onal and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certity that the contents of this consignment conform to the terms of The attached EPAAcknowiedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)[f I am a large quantity generator)or(b)(f t am a small gtran*generator)is We. <br /> Ger�p.*eslDfferor Printe Name Signature Mort Day Year <br /> �JC'lll�l' 'I 1�� X5 .1 l t <br /> -�-1 16.Intematonal Shipments <br /> P-- ❑impart to U.S. ❑Export from U. Pyr[of entrylexit:. , <br /> Transporter signature(for exports only): ata leaving U.S.: <br /> W T 177...TransporterAcknoMedgmenl of Receiptof Materials <br /> �r rte r 9 ledlf�d Narr�� ' S !ureth %Qaye <br /> Ix <br /> 1 a.l .ILI Jj-1(7� . <br /> f!l <br /> Transporter 2 Pr nledffyped Name <br /> Signaturif Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Ouantiiy .. ❑type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> MIN PAFSW=— WA-0:6- <br /> 18b.Alternate Fadtity(or Generator) DISPOSAL,TUATAENT OR MSE CROSBY Z.OV ERTON, PAC1LM uNL": <br /> .. t1'r31MS GRANTED TO TI•tEA1;BY THE DEPARTW.NT OP TOXIC SUBSTANCE CONTROL,TOGETIUs1 . <br /> 'NnH THE ENVIRONI+EN17AL PROTECTION AGENCY 1N A CORDANCE WMI TtIS PROVES10IrS OF <br /> L<L Facilltyrs Phone: "M-RESOURM CONSERVATION AND RECOVERY ACT ]F 1976 TOGLT]•IEP.WM4 APPLKAIILE , <br /> Q ISc.Signature of Alternate Facility(or Generator) sTF w� yl %n..rs ar <br /> Day . Ye . <br /> Q 34R1A7r9 To ACCT'THP RFFT-MENCED WA STI?AMP ALL-FW-wnN r <br /> Q19:Hazard s sle Report anagemept Method Codes(i.e.,code For hazardous waste treatment;disposal,and recycling syslems) <br /> n 1. <br /> 12. I'- <br /> 20.Designated FaMity Oviner or Operator.Certification of reeelpt ot.hazardous atedals vered.by the manifest except as noted In Ilem lila <br /> I'dwedlTyped Na signature °^Ili D y <br /> EPA Farm 8700-22(R v 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENEFtAT R <br />