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%tgOrder#:593852-03 Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator tD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL000331266 2 80"33-8253 �L, 6/¢ (7®� ®1/��T 5.G nerators Name and Mailing Address Generator's Site Address(if different than mailing address) Ke�fy Moore Paint Company 3206 E Hammer Lane Suite A 301 W Hurst Blvd Stockton,CA W212-28'14 Hurst,TX 76053 20"74-3706 Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number Ingenlum Sacramento("`ERI 876"004` ') CAD000626325 7.Transporter 2 Company Name U.S.EPA ID Number Ingenium Santa Clara( "ER)8766-0002-') CAD000626325 8.Designated Facility Name and Site Address U.S.EPA ID Number VLS Quartnite AZR000526949 3215 West Dome Rot*Road Quartsztte,AZ 85346 g28- ?_5-2580 Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class Nut 10. tainers 11.Total 12.Unit 13.Waste Codes HIM and Packing Group(if any)) No Ty pa Quantity Wt.Nol. NaWRCRA HAZAROo s WASTE LloU[Q(LATEX PAIN SPILL CLEAN UP) z 2. rst C7 3. 4. 14.Special Handling Instructions and Additional Iftmatio 01:(QZ347SWTE)LA T EX PAINTS LL.CLEAN UP Centrad tetatned is + Y genera4�r rarfsrn aget�.y e+riraery ntc irektei tr:tuparter to add or suhstrittt3 addrtatat 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,aril are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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 1 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 16.International Shipments ❑Import to U.S. ❑Export from U.S_ Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O Q W Transporter 2 Printed(fyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication SpaceEl ❑ ❑Partial Rejection ❑Full Rejection Quantity ❑Type Residue j j Manifest Reference Number: 18b.Altemaie Fadlity(or Generator) U.S_EPA ID Number U Facility's Phone: ' 1k.Signature of Alternate Facility(or Generator) Month Day Year a 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyclog systems) 0 1 2. 3. 4. 20.Des gnated Fadlity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed lTyped Name Signature Month Day Year EPA Form 13700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM