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Please*t or .(Form desfgrwd for use on etite(12 Form ApXmed.OMB Pk.XW4M <br /> UNIFORM HAZARDMS 1.Generator ID M otber 2 Page 1 of 3.Etter Response PhareAtanffed Tmddag <br /> WASTE MANIFEST CAL000430390 1 877 258-8285 JJK <br /> Ira Tal Cenwr=cm FAN s9ae_�ame pimmar�ta�sr,measaad� <br /> 5508 Lanas Drive 345 Rattt#1Road <br /> Knoxville,TN 37909 Latttrap,CA 95330 <br /> cmmata.Phone; fQAA1 474-282 <br /> 8 Tmuportar 1 Company Mame <br /> U.S.EPA 10 Number <br /> Ponder Environmental Services Inc CARGOOI10 7 <br /> 7.Transporter 2 Cornpeny NmoeU.S.EPA DNurttber <br /> & Ecology Nevada <br /> Address U S.EPA ID Number <br /> 1"�95 11 M i S df t382tty <br /> may.NV 89IM3 <br /> FacM es Pbone 800 238-3943 NVT3300 0000 <br /> 9a. So.U.S.DOT Dewoon OducUr9 NpM&#UV R me,Hm-d Visa.ID Number, 10.ccrdetners ii.TORI 12.Una 11 Codes <br /> Km and Paddng Dop(d any)) No. Type wtw <br /> t. <br /> Non-#MCRA Hazardous Waste.Solid(Oily Debris) W� `2 <br /> — DM 'sop P <br /> w z <br /> 4. <br /> 14.spmw frdanta4on <br /> Prefile# 70128300-28324 <br /> PO W47731 <br /> Job#120-18299 <br /> 15. f+EMATORWREIMS CEFMRCATM I hereby dedma that the contetb d ft oxrstg<m sM ma ft*and==a*desubed above by the groper d#bv Hama,rad ere datsl 4 packaged <br /> muW end tebetedlph=dA and ere In ag respects In proper vauEU I for trarnport sok fft to mrd tm'3auf govemmanhd keguta4or>s H ermert dtya>ent and I em Qse Prfmmy <br /> E)portm,I mr*that the oattm 1 of tide oor>0=Vrd oadm to the temrs d the atisd>ed EPAAdmoftnent d <br /> I cerffiy that the waste mtrdmtm8on statatrent Ids fed In 40 CFR 28227(e){Q I em a terga qua2y or @) a gc-ty 9 Is true <br /> kanreDay <br /> You <br /> 03 f?&4 Ir I <br /> 18. 1:1to US. ❑E)wit from U S. Pal 01 entryfandt <br /> Tmupom dgnshne(for mot ons# Date!eating U.S.: <br /> 17.TransposterAdkrror,4edgrtrerd d Rts7atpl ot!!affittab <br /> ?- 2-o <br /> r 2 Month Day Year <br /> 18.Dtsaepancy . <br /> 18a Dtsaepeocy trrdtmEan apace ❑ Y ❑Type ❑Re". ❑Parw Rejection ❑FW Ref edion <br /> Matdest Peferonce Member: <br /> 180.Admnete Faddy(or Oerador) US.EPA ID Rummer <br /> V <br /> Facftls Phare: <br /> w 1 Slgnabas dARemite FacC4 or Genwabw) month R ear <br /> 19.Hwtdaa Waste Report Umagemud Method Lodes(Le,cedes for hams as wasts tralltment.disposal.and-Ycn g systeUJ rts) <br /> G 1. 2 3. 4. <br /> 1 <br /> 2R Deskncted Fed2ty Omw or Cparstor.Cert18 dm of mceo of haxerdots materials omnA by the mmdast aoW as noted In tram 18a <br /> EwlISSgnsCns Month Day Yeer <br /> EPA Form 87 '22(Rav'MS) PnMous eOlom aria obsatet DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />