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• <br /> 17- 1457905 <br /> type.(Porto desi nod(w use on Hite(12-pitch)rypewritec) Form Approved.OMB No.2050-0039 <br /> ORM HAZARDOUS I.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.MaaNeM Tracking Number <br /> WASTE MANIFEST .,.--F :,, „_ 000053023 DAT <br /> 5.Cenamtoes Name and Mailing Address Gene SO Address(it dinerent than mailing address) <br /> 'PNBRRB PUROLEUF 5140 SIMARD PETROLEI.@' VIO <br /> se i9TN7OP RB 1i6 LATTIROP RB <br /> Gerreratals Phone' D^ e R i" 7 6 - <br /> 6.TranV iCompamy Name .S.EPAIDNumber <br /> ^an+nn ' it nf Cald fn,nrlA P n 9 <br /> 7.TratrMorer 2 Company Natne - U.S.EPA ID Number <br /> 0,Designated Fadltly Name and Site Address U.S.EPA ID Number <br /> KAEP.k ERIIRONRERTRL t%T, LC BRA PSC ENIIMENTAL SERICES <br /> 1155 I41TE ROCK. ROAR <br /> FadR s Plane: r <br /> ga. 9d U.S.DOTDescripinn(Incbtlug Proper SNpping Name,Hazard Class.ID Number, 10.Containera 11.Total 12.Unit <br /> PM and Packing Grwd(if any)) No. Type i <br /> 1 0—* WLNoI. 13.Waste Caress <br /> 0 LINT 3 JRSTE GASOLINE ; PGII MIMI DOR1 BBIB Ota <br /> Q :4 D11 v <br /> Ed <br /> w <br /> w z. r-3677 HAZARDOUS WASTE, SOLID, N.O.S. (GASOLINE, OIL WAMINTE3 1918 352 <br /> X RAGS) 9 PGIII DCI r�� P <br /> 3. <br /> 4. <br /> r <br /> ia.Special Handing Inerwlnm and Additional Inionnatim <br /> (2) �.y <br /> t1l 532223-00 - ERM12B) TUEL/YRTER MIXTURE 5]2224-00 - M1JB <br /> 171) RIS CONTNMTI M d ! X 97!<'P ` <br /> .Q ill <br /> ]� I xSS'Dje1 <br /> 15. GENERATOR'SIOFFEROR'SCERTNCATION:IhesbydedamlhaldrawntaradMbwnsonwt ehNymda=nWydowtedabmeby Nepmpwshppngmme,aw"chssfied,parlaged, <br /> narked adbbeledpilecerded,and are inalrespac4in Propeoonddw fetaMMawanagbappiabh Inbma6omlarldmllmalgorermmwtaliegilaip .Reapod shlpmenlaW Ism be Primary <br /> Exporter I sorely dal the wnhuft dMbcwsignment contain to the arms dthe attached EW.Mroabdpmd dConsem. <br /> I certify Out the waste minimization statement intended In 16 CFR 26217(a)(it]ana lags perilly gareralor)w(b)(#I am a small quantity gar"')1,to,. <br /> retorWerafs PdntedRyped Name Mont Day Year <br /> - 3 2 <br /> 16.Internal Shipments <br /> s- <br /> El indon"t U.S. Ecperl koro 7.S. dentryleaR <br /> No"= TmnsporlwsigmNre If"Noonly): sleeving U.S.: <br /> ,d 17.TmspmtaAdmxkdemeNafReceipt dMaterials <br /> Transports VACWdMW Names p Sigmsre mum Day Year <br /> yr <br /> Q Transport,2 Prints yped Name Signature Mae Day Year <br /> z <br /> ti <br /> 16.Discrepancy <br /> Ba,Dbcrepa Indication Span ❑ uaney Type Re a ❑Partial Relation Elul Rgecam <br /> /AR_ f`" An* /I s1'juw Ud 6 e P�r -�D/xo s�n�%,. <br /> Manliest Rele ince Number: <br /> lab.Ahemate Fadtlty(or GenemsN U.S.EPA ID Number <br /> U <br /> FacWs Phone: <br /> I Signature of Alternate FriOty(or German) Month Day Yea <br /> 19.Hazar <br /> dous;Waste Report Management Method Cadea(i.e.. <br /> codes for hazardws waste lmadrant dgmsal,and ral systems) <br /> 2, F J f l I 3. -T- <br /> 20.Designated Facility Oona a Operator Cslhcatbn ofmcelotof hazaroou4 mmenab wvaed Sy Ma manXf lerceplasloaderlam16a <br /> 11 P �pedry oatMORE bey <br /> ^1 1Q <br /> EPA Form 8700-22(Ree 3-05) Previous editions are obsomte. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)_ <br />