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2291.75-20 ERI Provider: SES - <br /> Please print or type. ZI 35 .2?/3v 13 Form Approved.OMB No.2050.0035 <br /> UNIFORM HAZARDOUS I'-Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man'MestTracking Number <br /> WASTE MANIFEST CALDuIIlJE47� 7 Cy 000307896 DAT <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than miring address) q, <br /> CE4''4 qL VALLEY USTE SE9`d2CES CENTIML VMM LUSTE SEVICca <br /> _71333 F TUNER 4S 1333 EAST TUDER 5 t <br /> GeneatotsPhone: L9DI GR 95249 (53W)27 -72i3 P BT P 7 ` <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> STPRICYCLE SPECIALTY WASTE SOLUTIONS INC MNS00011,0924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number `'y+' <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> I UHTT-96 KESOURCES LLC M <br /> 905 E. Francis St. <br /> Facility's Phone:OkfffllR14D, -M 917411 (909) 923-7252 1 cQpnnin S�q <br /> ga 9b.U.S.DOT Description(nduding Proper Shipping Name,Hazard Class,ID Number, 10.Containe s 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(Many)) No. Type Quantity Wuvc. <br /> Q, 1-UN3152 4'(!LMOGc 1RTH 32I4'OR111S, $ MB EvAUJgSTS) 9 4'61.1 512 s`d <br /> V f!O(L'@=�' iDCi K <br /> LU 2. GJ&N-RGN HANUOUS NSTE SOUT, 00-MLIGHT EALLHSTS) 512 <br /> DM -7-60 P <br /> 3. <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Inferrnation y <br /> (I) FSF4L M32B-B3 - 76(171) LIBRT 11ALLASTS, TSCA (2) UHLOBII35-93 - LIGHT ;ALLASTS FOP, 021 <br /> 412012020 NIQUE S 42929 <br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)CM I am a large quantity generator)or(b)(ifI am a s II quantity generator)is true. <br /> tofs/OfferoYs P'ted/Typed Nae Signa a Month Day Year <br /> elf <br /> � 6.liemonal Shipments ❑ t <br /> Import to U.S. ❑Export from U.S. Port of entry/exit E, <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W. 17.TransporterAclmowledgment of Receipt of MaterialsLU <br /> 4, <br /> Tran porter 1 P'tedfryped Name Signature Month ^�D,aayy Year <br /> a V 6/l! Y v`� <br /> 4 Q Tra orter 2 Printedlryped Name Sitgrr�ture Month Day Year <br /> 1115 j" <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ��9//� Quanti ty L, <br /> � ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> ( <br /> Lfnc ( zto}L �' <br /> un <br /> Manifest Reference Number. rr <br /> EPA ID <br /> 18b.AltemateFaaBU.S. Number Facility 9 ���4 n p� L))5/�( <br /> I <br /> Faeirys Phone `f �� (eiti ,11111 <br /> W 18c.Signature o iemate acuity(or Generator Month ay Year <br /> li VVi 19:Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ILLI <br /> 4. y `: <br /> do d I�f 0 qo <br /> ZO:Designated Fac Gty Owner or Operator CerGfiw' of recta of hazardous matmids covered by the manifest except as noted In 1 <br /> Prin ped Name <br /> Sj Month <br /> g�Y :r it ,i7 <br /> P,A`form 8700 22(Rev 1217) Previous edthons are obsolete. DESIGWl11 ED F�iCTY�j�r � r5 f= a51fS�1f ��j '�t <br /> � Y ra K I <br /> fu. ,l �'.,6...su..,." <br />