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Order#_ 593662-08 <br /> Please print or type. Form Approved_OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of i 3.Emergency Response one 4.Manifest Trackin Number <br /> WASTE MANIFEST CAL000331266 2 800-633-8253 000514571 ®AT <br /> 5.Generator's Name and Mailing Address Generator's 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 209-474-3706 <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Ingenium Sacramento(***ERI 8766-0004"*) CAD000626325 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Ingenium Santa Clara(*�*ERI 8766-0002`") CAD000626325 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Pacific Rcasou"Rewvary Setvtcel CA0008252405 <br /> 3160 E Pico Boulevard <br /> Los Angeles,CA 9W23 800-4S9-7145 <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, W.Con iners ti.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtJVol. <br /> rr 1. 352 F003 F005 <br /> O UN3175,WASTE SOLIDS CONY KING FLA4 LE LIQUID, .O.S. <br /> (METHYL ETHYL KETONE,ACET NE),4.1 , 1 0001 0007 D035 <br /> z 2. <br /> L RQ,LIN1263,WASTE rT RELA ED M ERI 3, PG 11(RO= 331 D001 <br /> f?001) <br /> 3. <br /> RID,UN1950,WASTE AER C7LS,F MA LE,2.1 Q=0001) 331 0001 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 01:(22132844)EfAFTY INDUSTRIAL CONTAINERS 03:(22132613}AEROSOL PAINTS <br /> 02:(22132612)OIL BASED FAINT LOOSEPAQK <br /> U4*-dd retained tnV gene.'atof Wlfefs agency authu*en inklai transportar to add or substitute additional <br /> 15. GENERA OR'S/OF rRORS 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 EPA Acknowledgment 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 Printed/Typed Name Signature Month Day Year <br /> J 16.international Shipments <br /> ❑Import to U.S. ❑Export from U.S_ Port of entrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name Signature Month Day Year <br /> O <br /> a <br /> Z Transporter 2 Printed/TSpc�Name Signature Month Day Year <br /> 18.Discrepancy <br /> 1 Be.Discrepancy indication Space EJ 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 /> V <br /> uQ. Facility's Phone: <br /> 1 Be.Signature of Alternate Facility(or Generator) Month Day Year <br /> d <br /> Z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recy*g systems) <br /> 0 1. 2. 3. T <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/ryped Name Signature Month Day Year <br /> EPA Fomi 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />