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r r�. 1 <br /> • O v l� 833482 5791 <br /> • Form Approved.OMB Na.2050-0039 <br /> Please pant or type.(Fon designed for use on elite(12-pitch)typewriter.) 2Pagelot 3.Emeryenq Response Phoma 0.ManMaN Traeklrlg Number <br /> UNIFORM HAZARDOUS ,.Generator ID Number ) 57 JJ K <br /> WASTE MANIFEST CAT1000171645 eneretcafs S'AeAddress(B tlMerenl Nan mailing address) <br /> 5.Generatoes Name and Mailing Address Hon MOT 8®5516 <br /> H01S MOT CI0 38 CORBY 711 D'AW PAIIIAY <br /> 1915 ASTO1 AP8B08 8181 LATHIOP CA 95331 219 858-5513 <br /> GanamlorBABL89AH CA 92118 811)151-8346 U.S.EPA I5Number <br /> 6,Transporter,Company Name CAROW164012 <br /> 21st CEIIMy IM U.S.EPAIDNumbar /J <br /> 7.Trensponer21 fCoompany Name rr �Z 06 O ejQ -77�Q <br /> SLI EPA 10 Number <br /> B.Designated Facility Nemo and Silo Address <br /> BDILIAGNI K17110111MAI, INC. TOY FACILITY <br /> 21245 77TH AVIM SODTH WAD991281767 <br /> Facility's Phone:: IBBT, AA 98132 (253) 872-8131 <br /> 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. and Packing <br /> Description any))Including Proper Shipping Name,Hamad Class,ID Number, No Type Quantity WfNol. <br /> HM and PecWtg Group(A any)) <br /> 1. r OoI . <br /> 0 2.1 DOT-se1zA42> FQ(On1=111): 0010 p, <br /> W1 0 35 331 <br /> OQ� �4 Q1P' <br /> P <br /> 3 <br /> 4. <br /> Duz 122 <br /> HYDIOII08, POTASSIDI HYDIOfIDB) B PGII' IQ(0112=111) oan- <br /> 14.Special Handling inMruceonsaMAddibonallmicarnation 7 X (X "' I� <br /> (1) 110182.1-13 - EAG(126) ABAOSOLS (21 80183-13 - 81G(128) F L6 L003KPICK (3 . <br /> SI�Rt#G6 (1►:BOIBBB-13. <br /> KEG(154) ALIALI318/eMOSD18LPIOPOSAL8.241IDU EMIUCY COHACT: (811)'151-1346- <br /> ,5. GENERATOR'SIOFFEROR'SCERTIFICATION: I hereby declare Net the contend of Nis consignment are fully and amuretaly desalted above by the parper shiDPing name,and are classified,packaged, <br /> marred and labeledlpdcarded,and are in all respects in barber condition for transport according to applicable Internationals <br /> national gwemmental re9ula6ow.lf export shipment and 1 am the Primary <br /> Exporter,I redly Nat the contend of this consignment=to=to the terms of the oriented EPAAnknowiedgmenl of Consent <br /> I certify that the arde minimization statement idon5fied in 40 CFR 262.27(a)it l am a large quand"onamta)ar(h)(dl am a small quami enereMQ is hue. Monty <br /> Signature <br /> GenemtofsfOfiemts 'ntedlTyped Name�� ,C 0z I� Q <br /> lt <br /> 16.Inteme6anal Shipments Iva' ❑Export from U.S. Pod of entry/ <br /> i ❑Impoa to U.S. Date leaving <br /> Z Trsnsportercignature(for, exports buy): <br /> w 17.Transporter AckncMedgment of Receipt of Materials Monty Day Year <br /> SlgnaWre , <br /> C Transporter 1 PdnledRyped NamerQ 7- iJ ch <br /> SignaNre Monty Day Year <br /> 2 Transporter 2 Prm7ryped tedName /� 2 <br /> F O B Uzi UaQRC-CA- <br /> ♦ 18:D)scrapancy <br /> iBa.OiscrepancyIndication Space El Quantity ❑Type <br /> El R.M. ❑Partial Reiroton Full Rejection <br /> Manifest Reference N.r <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility for Generator) <br /> J <br /> QMonth Day Year <br /> aL Facililys Phone: <br /> w 18c.Signature 0 Alternate Facility(or Generator) <br /> a <br /> 19,Hm dous Waste Report Management Math od Codes Q.e.,codes for hazardous waste treatment disposal,and recycling systems) 4 <br /> W 2. 3. <br /> Q t. <br /> i <br /> 20. a bred Facil' Ownero operator.Cam tonoF receipt in dous matadais covered by the manifest a teen interni _ Mon Day Ye r <br /> gra <br /> ) Print edAa .... _ _.. <br /> ATION STATE(IF REQUIRED) <br /> 1 EPA Farm 8701--22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO D <br /> 1 _ <br />