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Freesephntor Form Approved,OMB No.2050-W39 <br /> UNIFORM NALAROOMS 1,GeneiatorlD Number 2.Pegs 1 of 3.Emergency lWporm Phone 4.WONno mber <br /> WASTE MANIFEST C A R. 9 6 4 8 1 - 1001 1 J 9 Q VES <br /> 6,Garteratara Name std MaRry Address YULISSA GALVM Genwato s 9naMrs pralrtarenttnen mong OWN") <br /> FED GR U Y SAME <br /> TRACY GA 95377-7217 <br /> t3enmhft Plone: <br /> 9.Transporter 1 Company Noma U.S.EPA 11)Number <br /> VEOLIA ES TECHNICAL SOLUTIONS N 3 D 0 8 9 6 3 1 3 6 9 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> TRISTATE MOTOR TRANSIT CO. M o D 0 9 5 0 3 8 9 9 8 <br /> 9,Designated Fafty Name and SiteAddress VEOLIA ES TECHNICAL SOLUTIONS, U.S.EPA ID Number <br /> L.L.C. <br /> 1704 W.FIRST STRERT <br /> Fad a Phone AZUSA,CA 9179 C A D 0 0 9 3 0 2 0 0 3 <br /> 9a. fib.U.B.DDT D&Aiptlon(hduding Pmper ng Name,depend Ciaee,ID Number, 10.Gomafners 11.Total12,Unit 19.Waste Cafes <br /> HM and PackIN Group(If arty)) t1o, type Quantity WWW, <br /> X 1' UN 993�1 g�� AiSTt I1�)LSAP�ITHA)}, [?091 <br /> g � 1 1 D F 1 5 3 P 331 <br /> 6 x z' UN1993 WWASTE MARL$LIQpUID a.s. D001 <br /> 0 f i"8OPRU *OH04 ALO)1:VERA Cr L,3,1I <br /> } W I D F 154 P 331 <br /> 9 <br /> (0 <br /> YI ENE fj IOLj 3 LIQUIDS.n.n.s.. U239 213 <br /> 331l ggpp I D F 2 4 0 P D001 <br /> X 4 T ,T s T 1BB�C6NT��NATED!WITEIdHAHLS 3 'D F 1 4 1 P D001 357 <br /> 14,Special Handling Irehtxdlorts andddAddiBonal Wo matlon ER Service Contracted by VESTS + Cour retized by eeera for <br /> :71 <br /> a go � n 1 AC ,7) RG 29 W.nImal trans �I� �A 3}� 8%�Y�71604 AZUDPPK3 14)ZRG: <br /> 15. GENERATM80FFEROR's CERrFICATION:I"dedare hat the corm*of this oonefgoment arefully env aoasaEely tlesalbed above by the proper shipping name,and are dasaW,packaged, <br /> marked and lahaledlplacandad,and are In all Feapeda In proper cotatkbn for transport aoeotdbtg to applicable Inbmelfa3el and natlonal govemmmial repulaftw.If export shtprwt and tam tits Primary <br /> Engppter,l certify that the oorreattte of tlde oonalgrrrtent contomt k Vts forme of 8o alindted EPAAckrtowtedgntent of ConasN. ', <br /> I os*that ore wawa ummtcaibn abismantbarod In 40 CFR 282.27(8)Id I am a low quantify generator)or(b)01 am a sma8 quenbly generator)Is tam, <br /> Goneralarswerore frame %nat" ear <br /> "Ohw A --AT XL- LK 1Vh&Sq 640VOOIA <br /> 16.1 <br /> E_._I Import to U.S. t-._I F*artirom U.B. Port of eahylexfk <br /> Tmnspoder elgnabae(for exports QW., Date leaving U.S.: <br /> oG 17.T*vortwAr#ro+dedgnrenl of Receipt of Moledals <br /> Pd Sig I)ay Year <br /> glpnehsa MonetDay Year <br /> o 140 1w <br /> f8.Dlsd�eparwy <br /> tBa.DWnpawy trd1cre8on Spam Q t1ttanaty Q ve ❑Reektus ❑Partial Rejedon EIFou Rejediort <br /> Mar <br /> pkat BdM Number <br /> 18b,Alkrrtate 1<ac9lty(or c3erteralrsr) U.S.EPAID Number <br /> U- Fadityrs Phone; <br /> 1 Bo.64natore of Abmate Fack(or LienWBIDr y ear <br /> 19.liavuxi a Waste Report Management*0*Codes 0 a.,wdas for hawrdats waste heat wt dtspasal,and WON syAims) <br /> a 1. I,. <br /> k141 <br /> 3. � i4.esigner20.Dnated Fadily Owor Operator: tion of of hombres matsilals oowW by he manlL}`feallexaept as rtded in Rom 18a <br /> PdnWyped Nam -q y0or <br /> V01 inl= 1!!a)j �— .ffil-1N---?.Q <br /> EPA Fon87W22(Rev.12 WM od ons ere obiNe . DESIGNAT FA UTY TO EPA's e-MANIFEST SYSTEM <br />