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p ; Order#_593662-02 <br /> Please print or type_ Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFEST 2.CAL000331266 2 800-633-4-8253 1000514570 DAT <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Kelly Moore Paint Company 3206 E Hammer Lane Suite A <br /> 301 W Hurst Blvd Stockton,CA 95212-2814 <br /> Hurst,TX 76053 20?474-3706 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Ingenium Sacramento("*Et318766-0004*11) CAD000626325 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Ingenium Santa tiara(***ERI 876"002Y*") CAD000626326 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Covarita Environniental Solutions LLC <br /> 6626 Old porter Rd INR000127621 <br /> Portage,IN 46368 414-755-5352 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Container 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtlVol. 13.Waste Codes <br /> 1. <br /> t40ty-RCRA,KAZARoOUS WASTE LtQUI(3�W4,x P INT) 291 <br /> z 2. <br /> w <br /> C' <br /> 3. <br /> 4. <br /> i <br /> r <br /> 14.Special Handling Instructions and Additional Information <br /> 01:(1000136")LAT'EX PAINT LOOSE PACK <br /> Corti d fab*"d by gwceralor con'crs agarrcy sutirority do-tnftW transporter to add or substitute addidwal <br /> tautspW&on <br /> 15. GENERATOR'SIOFFEROR'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 contp ljs of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minim¢athn statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true- <br /> Generator's/Offerors Printed/Typed Name Signature Month Day Year <br /> 1G.International Shipments <br /> it ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> 0� IT Transporter Acknowledgment of Receipt of Materials <br /> OTransporter 1 Printed/fyped Name Signature Month Day Year <br /> c- <br /> ZTransporter <br /> 2 Printed/Typed Name Signature Month Day Year <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantit <br /> y El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 1 Bb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> CJ <br /> t Facility's Phone: <br /> 18c.Signature of Alternate Fadlity(or Generator) Month Day Year <br /> Q . <br /> 55 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycliN systems) <br /> 0 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certfication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />