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Please pant or type. �''�... Fnrm Annrnvari MAR No 9050-0099 <br />trmrormoruu-zctrcev. i&ir/ rreviouseaitlonsare onsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone 4. <br />Manifest Tracking Number <br />WASTE MANIFEST <br />1 <br />00 DAT <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />41y Moore Paint Company <br />I W Hurst Blvd Tracy, (:R 95376 <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />'-EPI R76R-(". 4'"') <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />pp / <br />,;.iP k t'fLtr 3J1XEVArCf sir\l. ijO8252'405 <br />Facility's Phone: <br />9a. <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any))13. <br />Quantity <br />Wt.Nol. <br />Waste Codes <br />No. <br />Type <br />1. <br />0 <br />Q. LIN 1263. iPr A'JTE PAIN f RELATED MATERIAL. 3, Pty U JRQ s <br />t` <br />� O <br />Z <br />2. <br />CD <br />UNI950, AEROSOLS, FLAMMABLE, 2.1, UNIVERSAL WASTE <br />I <br />3. <br />4- <br />14. Special Handling Instructions and Additional Information <br />D2: (L21 ?f4B81AER�5t?±.^ `X f ! �6S' <br />mklai rransmnar to add nr mrbsWe additimsM <br />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, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />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. <br />Generator's/Offerors Prinledlryped Name Signature Month Day Year <br />J <br />16. Intemational S ipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />F-- <br />K <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />LLI <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/fyped Name Signature Month Day Year <br />O <br />a <br />r <br />j <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />rai <br />Facility's Phone: <br />w18c. <br />Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed(Fyped Name Signature Month Day Year <br />trmrormoruu-zctrcev. i&ir/ rreviouseaitlonsare onsolete. GENERATOR'S INITIAL COPY <br />