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Please pflnt of tyre. Fwn AWv0d.OMB No.2US04" <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3,Emergency ResponsePlione rQ wMW <br /> WASTE AIANIFE8T ]4.Man" <br /> 00179800:1 VES <br /> S.Generetora Name and MaWng Address YULISSA GALVAN Gene"a Sits Addrdress(If dlflareat than malting address) , <br /> G55 MOOD WAY & <br /> RACY,CA;95377-7917 <br /> Generators Plwne209 <br /> 6.Tramporter 1 Company Name U.S.EPA ID Nurnbeir <br /> VZOLIA ES TECHNICAL SOLUTIONS <br /> 7.Transporter 2 Company Name U.S.EPA NO Number <br /> RISTATE MOTOR TRANSIT CO. IM 0 D 0 9 5 0 3 8 9 9 8 <br /> 8.Daslgnated Fadtlty Name and Slta Address U.S.EPA ID Number <br /> VEOLIA ES TECHNICAL SOLUTIONS, <br /> L.L.C. <br /> W. <br /> Fadtlys Phoria: jS-)jS 114,V111 <br /> AZUSAA. GA 917EET <br /> 02 <br /> 9o, 0b,U.S.DOT DwOtlen(ihcWW Proper Shlppbhg Name,Hazard Class,16 Number, 10.Contekhers 11.Total 12.Unit 13.W"to Codes <br /> HM and Packing Croup(If any)) No, Type Quentty WWaI. <br /> o >t 1 {UpN1993 ASTE FI.A.MMAHLE LIgUTAS,n.o,s, D003 33l <br /> F RAITNT)DIESELLIIGNITIOW IMPROOW ) 3.01 L ASER <br /> rg 1 D F 99 P D001 <br /> X 2' UN3972 WASTE ESTE n.a.sD001 <br /> 0-METROXY•9-24 1 LAWATE},3,Ill <br /> 3311 ��DI C F •1 6 P 331 <br /> x <br /> 3. <br /> I�UI ;WAST�Ep�RiS COMAMMA ED WITH <br /> F003 357 <br /> SO VENTS3,4.I.I 1 D F 19 P ID001 <br /> X 4 G N33 P P ii1R D PFSTICIDE, LIQUID,TOXIC, 331 <br /> 1 D F bb P <br /> 44, Handing Instructions and Additional Intomhatlon ER.Service Contracted by VESTS + Contract retained by enerator confers <br /> aEenr& �oriry nninitiai ttns�olterto add or substi�te adtli0onal transporters on tutor's behal 1E :198 Wl ' 1QA. <br /> 1 A: <br /> AZ APK3 PPACK 9)ERG:137 W:71i01 A AZURPK3 I�PACK 3 ER.G:I ':71548 A C 5 47 i ERG: 3 w: <br /> 15. OENERATGWSIOFFEROR'8 CERnFiCATtON7 1 hereby declare thatthecontents olthls oonalgnmsnt ere ruby end acaxe"desalbad abgo by Its prepersNppkV name,and are da"Mod,packaged, <br /> marked and labafedVwarded,and are in al respects In proper condgkxi fe Iranaperl aocadkhg ID eppbeabie IrdemateraE arw natonal govemmental setons.If export elhlfarrenl and l an tie Pft" <br /> E.xpoder,I corny that the conlents offt oonelgnmant conform to the terms of the alldW EPAAcko wledgmentof CDwnt. <br /> I certify that M waste Wnlmizatlon statement idedfled in 40 CFR 262.27(a)(t I am a largo quay*g6nora(or)or(b)off am a smab ghrartly generale Is true, <br /> GenaraWsK teroes Pdatodlryped Now S tlh Day ye <br /> j 16.Intoahatonal Sidpmems <br /> E ❑Import to U.S. ❑apm from U.S. Port of entryleyjt <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcluumledgmatofReceipt ofMetsrlaie <br /> T or 1 Pdn ante SignatureMon Day Year <br /> R <br /> � Tranaporter��- ams 51gna I A4whVr Day Yell <br /> ZL <br /> 18.Discrepancy rI <br /> 18a.Dlscreparwy lnd{cato+h Space Ousntty LJ Type ❑Residue ❑Penal RO)WI O ❑Fut R*d m <br /> MaWest Reference Nwnber. <br /> 18b.Allomate Facgity(orCaneralor) U.S.EFtA ID Humber <br /> i> <br /> I <br /> Fadlhy's Phone: <br /> 18c,S nature ofAlteohats Fadtty(or Generator) Month Dey Year <br /> 4z <br /> 19.HazArdous Wasta Report Management Method Codes(Ie.,codes for hazardous waste trsalroan4(gaposal,and recycling systema) <br /> 4. <br /> 20.Doaignatad FkIlly or Operaia:Ce tion of rvapcof haraldous materiels covered by tfhe nlanl bh Ilam 18a <br /> P pay <br /> EPA <br /> For-n187 22 Nev.12-M =edi are obsniete. D1:M ATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />