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� SLT '7x202 0 <br /> 845571 28785 <br /> Please pommy type.(Foran designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.Ganaratorib Nurrilbar 2.Pa d 3.Emergency Response Prions 14.Manifest Tracking Number <br /> WASTE MANIFEST ,77-2994 ,003895595 JJ K <br /> 5,Generators Name and Mailing Address S Genera101s SdeAd mss(Ifdifferent than mailing address) <br /> MOMS DEPOT C/0 36 COXPANY ROME DEPOT 185576 <br /> 1915 ASTON AVENUE 1188 181 O'AHCY PARBNAY <br /> Geneml <br /> 6.Transporter 1 Company Name US.EPAID Number <br /> 21-qt =IRY WT 2AROMIA401? <br /> 7B.TOmesnignertlaadr2Com ry a U. ID Ner <br /> J � 707 <br /> y <br /> Name and SiteAddress U.S.EPA ID Number <br /> BURLINGTON ENVISONNENTAL, INC, 101' FACILITY <br /> 28245 11TH AVENUE SOUTH <br /> FacllllysPhono: EENT, NA 98132 (253) 872-8131 WAD991281767 <br /> ga. go.U.S.DOT Description Wuding Proper Shipping Name,Hazard Class,ID Number, 10.Con r Typo 11.70411 12.Unit 13.Waste Codes <br /> HM and Padding Group if any)) No. Quarry WtNd. <br /> 1. 01951 1ASTE AEROSOLS, FLAMMAHLS, N.0.5. (METHYL ETHYL WOW 0111 D135 331 <br /> 0 R 2.1 DOT-SP12842 12(D101=111) 00 1, —1*4 0040 P <br /> 'DP <br /> Z. 11N1263 WiTB PAINT RELATED MATERIAL 3 PGII RQ(D811=118) D111 0835 331 <br /> \y 002, -w *.0 P <br /> bp <br /> 3. D <br /> R <br /> 4 <br /> r — <br /> 14.Special Handling Instructions and Additional information I X 3x 5 <br /> (1) HOM82.1-13 - ERG(126) AEROSOLS (2) HOW-13 - KIG(128) FLAMMABLE LOOSEFACE <br /> :24 HOUR EMHRGENCT CONTACT: (888) 451-8346 <br /> 15. GENERATOR'SiOFFEROWS CERTIFICATION:I hereby declare that Ma conte4s of this consignmemare fully and aavratety,described above by the proper shipping name,and am classified.packaged, <br /> marked and tebeledlplecarded,and am in or respects in proper condition for nummort according to applicable international and national governmental regulations.IfeVort smlpmem and I am the Primary <br /> Exporter.I coNfy that the indents of this consip mentoonfonn to the terms of the attached EPAAcknowiedgment of Donednl. <br /> I ceNly that thawaste minimization statement identified in 40 CFR 262.27(a)(d 1 am a large quantity generator)or(olpAim a small Quantity generator)is true. <br /> Ganeratofs'Olk dnledlryped Name Signature Month Day Year <br /> ,c s Olt 22- 10l <br /> J 16.International Shipments <br /> ❑Importro Us. Export from U.S. on ofentryli <br /> = Transporter signature for exports only): ala leaving U.S.: <br /> W 17.TransponerAckrawledgmere of ReWipt of Materials <br /> Hj Transporter 1 PrntedrTYped Name Signature Month Day Year <br /> 6 <br /> 0 22 a <br /> Transporter 2 Pdnted4yped Name SiglaW Monty Day Year <br /> B�1a4�D v y I Zia <br /> j16.Discrepancy <br /> 18a.Disaepancy Indication Space ❑ Quantity []Type ❑Residue ❑PaNal Rejection El Full Rojec4on <br /> Manifest Reference Number. <br /> Iso.Alternate Facirty(or Generator) U.S.EPAID Number <br /> J <br /> A <br /> u Faditys Phone: <br /> ¢w 18c.Signature of Arboreta Fadlity(a,Gererato) Month Day Year <br /> Y <br /> be <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes forhatardous waste treatment disposal,and recyclalg systems) <br /> 1 2. 3. 4. <br /> 1 20.Da!)EedFauflny,Cwmror0pieato, Cearrintiomof receipt of hazardous mawats wvemd a marilest a t as coded Ilam 18a <br /> Pante y ign Mapy Day Ye r <br /> EPAFcrrn870022(Rev.3D5) Previouseditionsarbotesolete. DESIGNATED FACILITY TO-DESTINATION STATE(IFREQUIRED) <br /> APR 20 rM 6:44 <br />