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NPlease print or tube. P7- a --4 nnA❑ ni )nvn nnvn r_rH r-orm oruu-« (Rev. iz-i r) Previous eamons are obsolete. GENERATOR'S INITIAL COPY UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST 100 DAT 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) -fly Moore Paint Compamf A W Nu!rrsi SAVd Tracy. CA 95376 Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number --E -R1 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number 6 t4evel uWs or Fasr i r u5S48Q5338 Facility's Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13. Waste Codes No. Type 1. ot1Lti'2924, WASTE FI A�AMABLE LIQUIDS, CORROSIVE, N,O S. ?ENESUI.FONIC v (� 1 7<s I DOI o Z ACID), 3 (8), PG 11 z 2. LU ON1791, WASTE HYPOCHLORITESOLUTIONS, a, 1'G III 1 1� V 3. ::. 'ESTE CAUSTIC ALKALI L"JID, N.Q.S. (POTASSIUM r rvnr111n!nCTt-tnr.r:, nsttt,tr,. )!d DF f.', r 1,peli 4. 14. Special Handling Instructions and Additional Information n2: iQS"R41S rgTrx.t rLnrp� sc - 0576/ •�2 15. GENERATOR'S/OFFEROR'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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generators/Offerors Printed/Typed Name Signature Month Day Year / 1-6. Internana Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: ? Transporter signature (for exports only): Date leaving U.S.: le w 17. Transporter Acknowledgment of Receipt of Materials F- Transporter 1 Printed/Typed Name Signature Month Day Year 0 a ti 2 1 Transporter 2 Printed/Typed Na Signature MoMh Da Year Day 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U rai Facility's Phone- in 18c. Signature of Alternate Facility (or Generator) Month Day Year a z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) � 1. 2. 3. 4- 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year r_rH r-orm oruu-« (Rev. iz-i r) Previous eamons are obsolete. GENERATOR'S INITIAL COPY