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ya © 1017026 126255 <br /> e 3 9 <br /> designed for use On elite(12-pitch)typewriter. FormAPProved.OMB No.2050-003 <br /> OwronM HAZARDOUS 1.Generator ID Number 2. eget f 3.Emerganq Response Phone en el rec nA um er <br /> WASTE MANIFEST CAR000171645 , 877) 577-2669 0 5 615 7 8 7 JJ K <br /> 6.Generators Name and MaRLpAddreea Generators Slt&Addmsa Af ddwntthan meting addle") <br /> Ho¢e Depot C/O PSC Attn. Hole Depot CSB HONE OEPOY 4HO5576 <br /> 5151 San YeIipe HOE DEPOT 4HO5516 711 D'ARCY PABHVAY <br /> GenareH8grg19�In TY 77156 866 313-7344 LATHEOP CA 95338 2119 858-5513 <br /> S.Trenepoder 1 Company Neme U.S.EPA ID Number <br /> 21st (fit MY OMMO1 M"n MANAGFRMT OF NEVADA, LL- CARM164012 <br /> arae S. m <br /> S.Dalpnaled Fadity Name 8usAddreu US.EPAIDNumber <br /> BURLINGTON ENVIRONMENTAL, LLC. REIT FACILITY <br /> -" <br /> Fac P ane:HEN4 WA-98832-(25?)-&72-8838 WAD991-281767— --Its. 9b.U.S.OOTOeasiollm(Indtdng PmperSNpping Nema,Hward Class,ID Number, ID.Contalnars 11.701e1 12,UNI 13.Wavle Coda <br /> HM and PacAmg Group 0 011 No. Type Ouandly WtNd. <br /> I. UN1956 WASTE AEROSOLS, FUNVABLH 2.1 OOT SP 11296 <br /> p ° DF P <br /> D08U 0835 331 <br /> w 2 ON1993 WASTE FLAVIAHLE LIQUIDS, AA,S. (ACETONE, NETHYL ETHYL 0081 0835 331 <br /> RQ INTONE) 3 PGII (FLASHPOINM1,01d) flQ(D101=181{ �j S0� P <br /> 3. UN28111 WASTE TOXIC, LIQUIDS, ORGANIC, N.O,S, (2,4-0) 6.1 PGII D816 0816 331 <br /> q[f_ 'TOXIC' EQ(0116=11) ( DFS$ P <br /> T 1� 4. UN3266 WASTE COO ➢ASIC INORGANIC N.O.S. (SODIUN 101112 jlZ2 <br /> POTASSIUW HYDROXIDE) 8 PGII 112M12=1el) P <br /> 14.Spedel Ing Ins WCBane eMAddiganei nfarmeticn ' <br /> (, 21 HONE3-14 - RIG028) FLANIAELE LOOSEPACI (3) HOME6.11-84 - EEG(153) <br /> TOXIC (LIQUIDS OILY) l8&BGSFVB 1PHOPBSAH} Q('✓ <br /> 1S GENERATOR'SIOFFEROR'S CERTIFICATION:Ihereby dedere that the contents of this oma�nmemam My and acnurately described above by the proper shipping nems,and medass&d.peckeged, <br /> and lsbeleNdacarded,and are m ell repeds 6In proper notam for transport ecoordng to Opp llcebl0 d natural governmentalmgulagms.If export shipment and l am the Pdmwy <br /> E IceM(y that the mmenaof he condgorrentcanto,m to Ne terra of the attached EPAAdmuwled orCansem. <br /> I c :the waste mIndrd akm Ism i d%d in4O CFR 2e237(a)(If f am a large qumtky uenere b)(dt am a small entity genemtoe is We. <br /> Ganesel ar rors Pdnto Nem Signaw � Month Day Year <br /> —s 18.IntambdonsJ61himeakis EIm to U.S. ❑Emxd from U.S. Port of mlryleAt <br /> Traroponat signature(for exports onty): Dela leaving U.S.: <br /> 17.TrempalerAdmmAedgmenlaf RemlplolMeton'els <br /> Transpo Yaw <br /> 1 P(d.ntedllyped Name SlpaWre month 2 7 JI, <br /> Trenepoda2Rin edfpype arae A .. - .. Slgnaw MmN Day Year <br /> r- <br /> 18.Disaepmcy <br /> Ite.DlsaepancYMdcadon Spam Ouaotty Type ❑Residue ❑Pardat Rdedbn ❑Fut Re)edlon <br /> Mandwl Reference Number. <br /> 18b.Altemate Facility,(or Generator) U.B.EFA ID Number <br /> U <br /> ut Fadltys Phone: - - - <br /> w 1Bc5gretaeofAltomate Fact by(. merator) Month ay Year <br /> . . . . . <br /> H19.HaTudousWaale RaportManegemenl Method Codes(Le,codas fmbanNaa waste treatment d'uposA,end recy6ng gatemo) <br /> t H141 2Heil @141 @t4l Fail <br /> 20.Oasignaled FadlBy 0%miw or Operate.Cag8ca0on oftecelptdhazaNaus maladatemveed bythammlhrtexgpteE noted lnitesa18c. - - - <br /> MI arae Stptmture r OOay YM <br /> r tea 16 <br /> =PA Form 81M22(Rev.3-05) Prevlousedlgats are obsolete. DESEGNATEDFACILITYTOSTINATIONSTATE(IF REQUIRED) <br />