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Please print or type, Form designed for use on elite ( 12-pitch) typewriter. Farm Approved. OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2, Page 1 of 3, Emergency Response Phone 4, MA Ifesl Tracking Number <br /> WASTE MANIFEST C A D 9 8 2 0 3 0 2 0 7 1 SW 877.7267 1518 8 5 3 811 JJ K <br /> 5. aattllpg Addtess n IMl98Ili9 Gen_ _ valor Sita drops (1 digere t than mailing address) <br /> 14W F'B��CRI * I ted m i WO IJnFC1�1 Rti <br /> Qnrehta NE 68179 Slbc CA 96208 <br /> Generator's Phone; 9 1 6 6400496 <br /> 8. Transporter t Company Name U,S, EPA ID Number <br /> Amett w Integmted Services, Inc. C A R 0 0 0 1 4 8 3 3 8 <br /> 7. Transporter 2 Company Name U,S: EPA ID Number <br /> vppmL) W U <br /> 8. D sl no ed Ficili ameeaan�d ii�ddress U,S, EPA ID Number <br /> 1�* IAhSheet SENT TO D " C <br /> Long Bomb CA 90813 - I a <br /> Fadlit sPhone: 6a2 4�'' 5w Date ; C A C Q $ 4 0 9 09 <br /> got , 9b. U.S. DOT Description (including Proper Shipping Name, Hazar6dlClass, 10 NUMD81p, ppp10, Container"Type <br /> 11 . Total 12. Unit 13:Waste Codes <br /> HM and Packing Group (if any)) No. QuanOty WIN01, <br /> IVN1993. Vli IE Flemrmble Uqulds, nos. (plrboleam it lits),% 281 331 D001 <br /> K PG 11 DM � G DIM <br /> ENNE <br /> W 2•N0n4WAA Hez fdM VMSUI Lkilgd (Isbpocic Mqulkis) 221 331 <br /> d !� DM Q <br /> Re 6 <br /> 39LNJ M9 V1b481E ConoW �e L4Wr Book, n.o.s. (SodMtutn "' xlde) D 122 331 0002 <br /> a PG 11 sFp 1I 2 19 1 t <br /> 46 INDIANAPOLIS <br /> 14t1W8VaVlND rpt ° VW4VAT rn%ndli. ng . We ghto or volumes are approximate . <br /> AIS Job : 74023 - 42 / WR1122026 / C&O Profile .OLP58816 <br /> et B l ) Ix E ajs2 t x q'6 l x 1 <br /> 15, GE RATOR11OFFER 'S CERTIFICATIONKI hereby declare tha the contents of this consignment are fully aftAmrately described above by the proper shipping name, and are classified, packaged, <br /> marked and labeledfptacorded, and aro In all respects In proper condition for transport according to appllcable 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 EPAAcknowlodgmerilq1t Consent, <br /> I certify that the waste minlmlzatlon statement Identified in 40 CFR 28127(a) (II I am a large quanOty ane tor) or O (If I em small qua lily Qtrue, <br /> GeneratoestOfferor's Pdnt(gTyped Name Signa a Month Da Year <br /> AIS On Behalf of Generator 1HOUghtafto `q <br /> r 10, International Shipments <br /> ❑ Import to U.S. ❑ Export om U,S. Port of enlryle <br /> Transporter signature (for exports only): Data loaving U.S.: <br /> 17. TranspoderAckrnowledgmentof Receipt of Materials <br /> Transporter ) Pdntedrryped Name Signature Month Da Year <br /> DanCYC_ <br /> Tran or 2 Pdntedrryped Name 5ignaluroU Month Day Year <br /> C� <br /> 18, Dlsaepancy ll----ll <br /> 18a; Discrepancy Indication Space ❑ Ouanlity ❑ Type ❑ Residue ❑ Partial Rejection 1 Full Rejection <br /> Manifest Reference Number, <br /> 18b. Alternate Facility (or Generator) U,S, EPA ID Number <br /> LL Facility's Phone; <br /> 18c, Signature of Alternate Facility (or Generator) Month Day Year <br /> N19; Hazardous Waste Report Management Meowd Codes (Le., VOSS for hazardous waste treatment disposal, and recycling systems) <br /> w1 . 2. 3. 4, <br /> � ` 4A 1t, A ( � <br /> 20, Designated Facility Owner or Operator; Corlificallon of recelpl of hazaKW& materials covered by the manifest except a noted In Item lita <br /> r <br /> ntedfryp d N �► n ,. n � Signature Mo Ih D y <br /> G 11�f/ 1Lc <br /> EPA Form 00.22 Rev. 3-05) Previous editions are obsolet . DESIGNATED FACILITY TO DESTINATION STATE (IF Fir` _ UIR D) <br />