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�s 3 <br /> Please print 0-rlype. �IIUII �itIII1ElI Form Approved,OMB No.2050-0039 <br /> UNIFORM IiA2AR000S 1•Generator ID Number 2,Page 1 of 3,Emergency Response Phony 4,Msnlfast Tracking Number <br /> WASTE MANIFEST0 017 9 912 6 VES <br /> 5.Generator's Name and Mailing Address �� Generator's She Address(If dtferent than mailing address) <br /> VAN <br /> RM EX GROUND SAME <br /> 5655 HOOD WAY <br /> j snore s CJY,P n0-%A:95377-7217 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> VEOLIA ES TECHNICAL,SOLUTIONS 'L�fv21 <br /> 7,Transporter 2 Company Nama....,hMn �V 5 , U.S, PA D N� <br /> � ` Q <br /> 8. 1 <br /> Designated Factlity No and SilarAffmas U.S.EPA ID Number <br /> VEOLIA ES TECHNICAL SOLUTIONS <br /> 7665 HIGHWAY 73 <br /> BEAUMONT.TX 77705 <br /> FacMy's Phone: <br /> go, 9b.U.S.DOT Desodption(Inducting Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WlNol. <br /> o DIN-RCRA HAZARDOUS WASTE LIQUID, (LATEX PAINT, 331 <br /> 4 D F 8 4 7 P OUTS2 t 9H <br /> i 2. <br /> LU <br /> ch <br /> 3, <br /> 4. <br /> 14.Special HandYng Instructions and Additional Information ER Service Contracted by NESTS + Contract retained byeneraloy Confers <br /> ajye t Yla�gority an initial tra vorter to add or substitute additional transporters on generator's behalf. + IM31519 A <br /> f6, GENERATOR`StOFFEROWS CERTIFICATION:t hereby declare that the contents of this consignment are tally and accurately described above by the proper shipping name,and are clasadled,packaged, <br /> marked and labetadlpfacarded,and are in all respects in proper condition for transport according to applicable intamationaland naltonal governmental regulations.tf export shipment and I am the Primary <br /> Exporter,I cardty that the contents of this consignment conform to the terms of Uro attached EPAAchnowtedgment of Consent <br /> I certify that the waste minimization statement Identified In 40 CFR 262,27(a)(If I am a large quantile generator)or(b)(if t am a small quantity generator)Is true. <br /> GenaraloeOfferor's Pdntedrfypod Name Signature t Mon Day Year <br /> YVAML 0 fak v <br /> W.InternationalShipments ©Import to U.S. Lltry <br /> Export from U.S, Port of en lexil: <br /> Transporter signature(forexports only): Date leaving U.S,; <br /> W 17.TranspoderAcknoMedgmenlofReceipt ofMaledais <br /> rtor 1 Printed me 5i9�wtrao�.. on Da Year <br /> g \«.`"+ <br /> Tra iter edfT ped ame S nahrre Month Day Year <br /> 1S.Piscreponcy <br /> too.Discrepancy fndlcation Space ❑ Ouanoly t. l Type ❑Residue ❑Partial Rojectfon ❑FuR Re)eclian <br /> Manifest Reference Number: <br /> 18b,AAemato Facitty(or Generator) U.S.EPA fD Number <br /> J <br /> L1 <br /> U. Facility's Phone: <br /> W sac.Slgnafura ofAtiemate Facility(or Generator) Month Day Year <br /> Q <br /> 19,Hazardous Waste Report Management Method Codes D,e„codes for hazardous waste treatment,disposal,end recycling systems) <br /> 1, 2. <br /> 20.Oasignalod Facility Owner o€Operaf%Certification of raceipi of hazardous materials covered by the manifest except as nded in Item no <br /> PrIniedlTyped Name Signature Month Day Year <br /> Qob akke&�— 1 � J001 Q <br /> EPA Form 8700-22(Rev.12-17 Previous editions are obsolele DESIGNATED FA IL1TY c EPA'5 e-MANIFEST SYSTEM <br />