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Please print or type.(Form designed for use on elite(12-pitch)typemiter.) Form Approved.OMB No_2050-0039 <br /> UNIFORM HAZARDOUS 1.Genefator lD Number 2 Page 7 of 3 Emergency Response Phare 4.fAaniiest Tracking NUm <br /> WASTE>AMIFEST CAL000430390 1 877 258-82$5 016012877 JJK <br /> 5.Ge. leis' Name and Marling Address GeneraWs Site Address(d di ferant than malling address) <br /> Pl of laveI CenterS LLC Frying J#1017 <br /> 5508 Lonas Live 345 Roth Road <br /> _ Knoxville,TN 37909 - Lathrop,CA 95330 <br /> Generalor's Phone 895 474-282 <br /> 6.Transporter 1 Company Name U.S,EPA ID Number <br /> Ponder Environmental Services Inc CAR000180737 <br /> 7.Transporter 2 Company Name U.S.FPA ID Number <br /> &Designated FaciRy Name and Site Address US.EPA 10 Numbef- <br /> UEcology Nevada <br /> Hwy 95 11 Mi S of 92211y <br /> Beatty,NV 89M3 <br /> FadTiys Phone: 800 238-3943 NVT330010000 <br /> 9a. 9b.U.S.DOT Description('vrdudirlg Proper Shipping Name,Hazard CUSS.ID Number, ID.CoaWners 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group Cif any)) No. Type Ouantily WM1Vd. <br /> oc 1. 0'8 352 <br /> a Non-RCRA Hazardous Waste,Solid(Oily Debris) as DM 1 S�rp P <br /> 4a <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions andAdditionai Information <br /> Profile X1070128300-28324 <br /> PO#747737 <br /> .lob 020-19289 <br /> 15. GENERATOR'SIOFFEROR'S C}R MCAAON:t hereby declare that the Contents of ttts eonsigrunent are kdy and ecumateydasrribed above by this proper shipping name,and are classified,packaged, <br /> marked and tabeled(placzrded,and aro In a3 respects In proper condition for transport according to tionai and rational governmental regulatJaq.N export shipment and Ian the Primary <br /> EVorter,l cad4 that the contends o(ft consignment conform toft terms Otte attached EPAAcknwA7wt0ftfnsML - <br /> I certify Cat the waste mQvr>Qatiar statement Identified in 40 CFR 26227(a)(d Iona large quanffiy g Orator)or(b)CNFLM a soaqwtity generator)is hue. <br /> Ga arators101f tedfryped Nama / latus Day Yeww <br /> I <br /> 1 16.Intarnabonal Shipments <br /> ❑Import <br /> to U.S. Export from US. Port Of errWerdt <br /> rts <br /> Transporter signature(for expoonly): - " Date leaving U.S.: <br /> IZ w 17.TransporterAckwWadgmentofReceipt ofMaterials <br /> r 1 PrintediTyped Name r� Sag Month Day Year <br /> I ci� I Z2 2.0 <br /> Cn <br /> Trans otter 2 Printed(Typed)kftne SignalhjA Month Dar Year <br /> roG jip4�.p Z_?-ne-4 2 <br /> 1-- <br /> 11 <br /> 18.Discrepancy <br /> 1 Ba.Dhawancy hkation Space ❑�>anfih ❑Type ❑Resdus ❑Partial Rejeedon ❑Fa Rejection <br /> Manifest Reference Number. <br /> 180.Alfemate FacWty(or Generator) U.S.EPA ID Number - <br /> v <br /> ua F.dliYs Phone: <br /> W 18¢.Signature of Altemata Facility(or Generator) Month ay Year <br /> Q <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes Q.e.,codes forhazardous waste treatment,disposal,and recyding systems) <br /> � 1. 2. 3. 4. <br /> 20.Designated/FaclllityDaworOperraWCetDrxaof recept of hazardous rnatedats covered byte rioted In ban 18a <br /> yped Nacre SignawfeAtarrtlr Day year I <br /> fil1� r111%V <br />