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Please PrIntortype. .I �[A �tl� }� Form Alipproved.OMS No,2060-OD39 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page t of 3.Emargoncy Response Phone 4,Manfhat Tracking Number <br /> WASTE MANIFEST VES <br /> 5.Genarato's Name end Mailing Address YULIRSA C4ALVAN Generator's Sb Address(H dhlerent than marling address) <br /> PED EK GROUND SAME <br /> 5555 HOOD WAY <br /> �"Y �e, 45377-7217 <br /> enerator,Pthona; 209 <br /> B.Transporter 1 Company Name U.S.EPA ID Number <br /> 39 to UT1CNs N l D 0 8 0 6 3 1 3 5 9 <br /> 7,Tmnaporter 2 Company Name U.S.EPA ID Number <br /> S.Designated Facility Name and SheAddrass U.S,EPA ID Number <br /> I VROLIAES TECWCAL SC7L1J37C KS, <br /> I L.L.C. <br /> l 1125 HENEXY STREET <br /> FadlitysPhow RIC11140M,CA 9481)] C A T 0 8 0 4 1 4 0 7 9 <br /> ga, 9b.U.S.DOT DaWptfon(including Proper Shipping Name,Hazard Class,ID Number, 10.Contalneis 11.Total 12.Unit 13.Waste Codes <br /> HM arrd Packing Oraup(Hang)) No. Type Quantity Wtivol. <br /> 1. <br /> 04 X LW161,WARTS IdCPUEp CCAS,FI.AMAfABLE,xwm, D001 <br /> (2.3.3.3-'Y'Ei'PAF'LUORCVPJXXI-6[�i),2.1 <br /> 1 C Y 13 P 331 <br /> Lu X 2. UN1072,WARM t7DCYtIIx 4,USED,2.2(5.IX RQ DOOi <br /> 5 C Y 44 P 141 <br /> X 3' UN1013,CARBON D3QXIIDE,(CARBONI Xt1XIMIs 141 <br /> C.ARTRI13D5813I PUNZrM TYM,2.2 <br /> I D F 23 P <br /> 4. <br /> 14.Special Handling Instructions and Addlffonsi lnfomhston WIL Setwim by VEM + Cadraet 1Ek*d by yeaerdw cocidkis <br /> n�►tt�rnmae r 04 <br /> ini1 1 tretl�aet�C�f111 ar au�sritl>laf s1l�itioa.I tc ta9po�ceRs oa 6+rhr1E + 1)E3LG:1 I5 W A015655 <br /> A:PT�W0I01 55 �>�:1 W:b0252SA:PTACYGOOS 3)E -.12OW:72026 TW0YGW1 <br /> 15. GENERATOR'810FIFF,ROR'S CERTIFICATION: I herebydedare that the contents of this conslgnmenl are fully and accurately described above by the proper shipping new,and am dassffled.packaged, <br /> marked and lebeleWplacarded,and aka in all respects In proper condition for transport according to applicable intemational and national governmental regulations.If exportshlpment and I am the Primary <br /> Exporter,I oar*that the contents of No consignment conform to the terms of the ataclW EPAAdm Wglment of Consent. <br /> I verify that the waste minimization statement Idenff%d in 40 CFR 282.27(a)(H f am a large quantity generator)or(b)(H I am a small quantity generator)is hue. <br /> GermwoeslOfforoes Print ypa Nart1e Signature _ Month Day Year <br /> it.International Shipments /y <br /> H ❑Import to U.S. ❑Export from U.S. Port of enWaxlt: <br /> ? Transporter sfgnalure(for exports only): Date leaving U.S,: <br /> cc V.TronhsporterAdumli4meni of Receipt of Materlal9 <br /> Transporter 1 FMnWffyped Name Signature Month Day Year <br /> 105UNE� 010 110 0 17 1 <br /> Trensporter2 PrintekilTyped Name Sign kre <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Qusntty ❑Type ❑Residue ❑Partial Re)ection ❑Full Re)edton <br /> Manifest Reference Number. <br /> 18b.Nlemate Facility(or Generator) U.S.EPA ID Number <br /> ua Facility's Phone: <br /> PU IF ;nalureofAllemaleFacility(or Genorator) Matth Day Year <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal.and recycling systems) <br /> 1. J 2, 9/Z// 3• //N/ a• <br /> 20.Dessf`gf naled Facility Owner or Operator:CaNflcathn of recelptof hazardous materials covered by the manifest except as noted In Item 18a <br /> PrintgdlTypedName � rgnatare Month Day Year <br /> !/T/wri� ' k10.1116 ZIJ <br /> EPA Form 8710.22(Rev,12-17) Previous ediflons are obsolete, DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />