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Please Print or type.(Form designed for use on elite12 Itch <br /> ( -p )typewriter.) <br /> UNIFORM HAL1f�D0" 1•Generator 10 Number Fonn Approved.OMB No.2050-0039 <br /> WASTE MANIFEST CAL000269375 2Pega1M 3.Emergenry Response Phone 4;ManNntTmcklna Number <br /> 1 B"'3'.-52" 0'08981694 'JJK <br /> 5. 1�"��f�tt9 <br /> 3927 C1erh Drive on Geaera1 is i dd s(yfliatent than maid' a dress) <br /> Stoelstan CA 95205 Stodr) DTrn'4G �� = Douq Grose: <br /> r CA 9520$ <br /> O1F <br /> Generalmfs Phone: 940-3065 <br /> 5.Transporter 1 Company Name <br /> Worldwide Recovery Systems, Ire_ U.S.EPA ID Numher <br /> 7.Trampartar 2 Company Name CAR000175422 <br /> i:.Name U.6.FPA ID Numhnr <br /> e•Ds9loneted Fadity aid at,pddr�ss <br /> OS EColo13Y (Ije=7' $p) U,S.EPA ID Numher <br /> Bi9t'neay 95, 1Ymi_ S_ of Beatty, P_D_ Bon 57B <br /> Eeetty, B9 89003 <br /> I'MilVs phone: 800-239-3-943 <br /> 90, 91p.U.S.DOTDasceegon(Induot'ng Proper Shipping Neme,Hazed Claes,ID Number, 30 1000f) <br /> HM and Pacift Gmup(dany)) 10.Containers 1"Idef 12.Unit <br /> w 1 Bon-RC&A W. Type Quaintly WWd 13.Waste Codes <br /> No, <br /> Berate Liquid (LeteM Peint <br /> Commodity pech) 291 <br /> CF 5 0 <br /> L 2. f <br /> 7 <br /> 3, <br /> 4. _- <br /> t <br /> 14_Special Handling lnshud/ons andAdtltional lnformalion i <br /> I <br /> 1) D7-013-1570-3093 <br /> Bill to t9arldwide; lefeer Appropiete protective Clothin <br /> 4; EB. Respansc worldwide Recovery <br /> 16. T0IPSIOFFERDR'S Cnd am CIn aVres Ihereby <br /> oper. tet Wew <br /> marhadand rlfaU/plara ompeterlfthisarespacLs in "N^Wof hilcenccerftl to a pptarefWYandaauralely tlesmhed ahova by thepmpersh' <br /> proper. th i emose Uaitsport acceding b appllwhle lntemedoneland natonal govemmenW mgulatmns.�expos sh'and mot i ve We Prhnagltl <br /> Exponet renty Thal to wnlenb al tYs mnsf9nmen(confomrto the tomo ofthe attached IFFAAchnowledgmanlofConsent <br /> I ceNy That the waste mYYmtraton statement identlfiad In 40 CFR 26227(a)(N I am a large guanWy ganamber o <br /> Gene a emrs - Name L ) Il guadly.genembr)IS We. <br /> S' <br /> Month Day Year <br /> 16.fnlemalion IShipmants q Its— <br /> C Y <br /> TmnsporterslgnaWre(for exports only): Import to U.S. ❑ExpodfmmU Portotentrylaxit <br /> 17.Trenspo WPOMovledgmenl of Receipt of Moderate Dale Leaving U.S.; <br /> rams/poi/a�/,PrtntedlTyped Nam/� <br /> �2✓� 9� � /7/� Montt DaY Year <br /> rensporler2 PrinledRyped Nama ���/( t �S )� <br /> Signature � <br /> Month Day Year . <br /> 1.Discrepancy <br /> W.Dlsoapancy Indiwton Spare 1 <br /> ❑ Quantity L-iTypa <br /> LJ Residue ❑PaNal RejeWon <br /> ❑Full Rojacton <br /> h.AI(emale FadNty(or Generator) Manifmf Reference Numher. <br /> U:S.EPA ID Numher <br /> Atys Phone: <br /> 91{pmlure atAllemale Facility(or Gananlor) <br /> Mont -Day Yaw <br /> Hazartlous Wavle Repan Management Meted Codes Ile,wdee for hazallous Waste treatment dispml,and <br /> 2 rarytling systems) <br /> 3. <br /> 4. <br /> ]esfgnaletl FadOty Owner orOperalor.CeNficdtlan of rewipt orhemrdaus meledels wvered by to manlieM except as noted in nem is, <br /> etl/yyped Name <br /> SlgnaWre <br /> Month Day Year <br /> r 6700-22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />