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oiaaca Ohl or type • (Form designed for use on elite (12-plich) typewriter.) <br />Form Annrnved. OMPI Nn ohe11 <br />E001Z00'd <br />Its are o so ete. <br />ZVIO BLS SOMMID <br />DESIGNATED FACILITY TO DESTINATION STATE (Or REQUIRED) J: <br />ZVI O-BLS(60Z) AIM01 06J089 ES:80 LIOZIOLILO <br />V <br />UNIFORM HAZARDOUS 1• Generatr ID Number 2. Page 1 of 3. Em¢rg¢ncy Rasponrs Phone 4. Maniteet Tracking Number <br />WASTE MANIFEST GALOOOt�631 1 203.948.0397-2062 01586 4 915 JAI <br />6 G pG�IrIsOA rpaD�rd.MalllpgAddreae Genamtpye SIM Address (IT WTI than malling addreea) <br />SSTT00�399�E <br />ts2oW, Waller <br />stod ton; CA SEW <br />e Phons: <br />GeneroW <br />6. TrenaP°ar i Company Name U.S. EPA ID Number <br />George W. Lowrp, 'no- CAR000047019 <br />- <br />ThensfName US. EPAID Number <br />, <br />i; <br />a, U,S.EPAIDNumber <br />St. CAT1; 3rd <br />CSO= <br />a7.7100 <br />Fad <br />• <br />gQ US. DOT oescrption (including PmperShipping Name, Hazard Class, ID Number, <br />10, Containers <br />it,Totei <br />12. unit <br />k- <br />ga. <br />HM <br />and PecMng Group ('darry)) <br />Quanti <br />wt.Nol. <br />13. Waal codes <br />No. <br />Type <br />7. UN 1263 WASTE PAINT REI-ATE4 MATERIRI FLAMMABLE L(GrUlq 3 <br />DM <br />G <br />214 <br />Uooi <br />(' <br />pGNI (DD01 <br />._ <br />_. <br />` <br />2 <br />3. <br />_. <br />H <br />4. <br />` �.I4: Special Handling insinuations anW Aetli6onal lnrorn'atipn <br />ERG# 128 <br />.: <br />use s i OYES INVOICE# -'i,�p��C✓ <br />}. DENERATowsioFFEROR'S CERTIFICATION: I hareby, declare that gee contends of this consignment are hilly and accurately described above by the proper shipping name, and are classified, packaged, <br />><p, marked and labeled/placarded, and are M all respects in proper condition for transport according to applicable International and national governmental negulatlone. If export sMpmem and I am the Primary <br />e porrEr, I os*Itretthe WMAMe Of this coaaignment conform to the tames of the attached EPAAcknowledgrrlentof Consent. If <br />Icanify that the waste minlmlaadon statement idehifed in 40 CFR 282.27(a) ()f l am a large quandry gerneratar)or 'lls) (if Ijrn a tpVcluenthy generserr) Is true. <br />dWrators/ORerore, Pn Pe a Signa <br />, <br />�NCe v � ®q <br />Month Dey Year <br />?(::: <br />1I6. InRmallonal Shipment import U.S. <br />s.. p ❑Exponfmm U.S. Pon oft nbylexit <br />`jYSlreportereignatur¢ (for export arm: Date leaving U.S.: <br />7ramPonerAcxnowledgmeMof RecelptofMaterals <br />rareporter l PrintedRyped Name - - 3lgnature <br />Month Day Year <br />� <br />roneporter 2 Ph peg Name Sign <br />Morith Day r <br />M 16.01screpancy <br />tat. Discrepancy ImAcI Space ❑Quantly ❑Type ResWua ❑ Fenger Rejecean <br />❑Full <br />R¢Janion <br />Manifest Reference <br />yBb,Altemate FecilAy (W Generator) Umber. <br />U.S. EPA ID Number <br />" 1�NIV/ Pion: <br />J cgneNrB ornate r-aamy (or Gang@tp - <br />M Day. ear <br />HbYazdous waste Report Management Method codes (Le., odes for hazardous waste tne30nent, disposal, <br />and repyding systems) <br />4. <br />p; Designated Facility Groner or Dperater. Certification of recaiptof hazerdoua materials covered by the manliest except as na¢d fi Item Ige <br />leOwlypea Name Signature <br />Moreh Day Year <br />'i`0 8700-22 Rev 9-rA% pmV1ous edifo b I <br />E001Z00'd <br />Its are o so ete. <br />ZVIO BLS SOMMID <br />DESIGNATED FACILITY TO DESTINATION STATE (Or REQUIRED) J: <br />ZVI O-BLS(60Z) AIM01 06J089 ES:80 LIOZIOLILO <br />