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01/28/2010 12 44 FAX <br />0 <br />Please print or(Fan designed forum on ellle 12 trh <br />12013/019 <br />Ct. 0 9504. 12 47 <br />Form A. red OMR No 2050-0039 <br />FPA Form 81*22(Rw.3OS) Pml=vditknsare obsden_ ESIGNXtEO F ON STATE (IF REQUIRED) <br />10270.1728 <br />UNIFORM HAZARDOUS t-Oe^e'smr lD Number <br />2.71 of <br />3. Dnagenry RasPh.. <br />T0. WXDVG NMW <br />WASTE MANIFEST CAL0002SW12 <br />800-747.6" <br />000237720 JJ K <br />5, OenenlGre Name and Malting Ad=m Genomes SIH Ad= (IdONronl Tan ne" adurm) <br />Tower Mart Store # 104 <br />192 Lathrop Read <br />LatMOD, CA 95601 <br />Genammre Prone: 976-285.7402 <br />O.Tnimponerl iyNemo U.S.EPA ID Number <br />UNIVERSAL ENVIRONMENTAL, INC. CAD983852M <br />7 TqnKqrwwt or", <br />W Nemo '" U.S.EPAIDINmba <br />/J <br />l <br />Iy��e��r�dy�Id <br />@e Ady a <br />e. Deruo�OSB'F /WU OVERTOIV .. EPAID NunEs <br />11630 W, 1TR1 ST CAD0294090f0 <br />LONG 6CACH, CA SWI3 <br />1`86110 Phw 582-432-5445 <br />9a. <br />5D. U.S. DOT Desalploe pnwdng Pmpu ShiDPb6 Nanm, Hamrd Cl as ID Numbw, <br />10.OWalnery <br />11 ToLd <br />12. My <br />HM <br />am Paodry Gmp ill any)) <br />Qua" <br />wwd. <br />73. Wmn Cadea <br />No. <br />Tree <br />X <br />1- I'lpimbla Waste Liquid, N.O.S-, (waler W/gasogne), 3, LJN1993, PO11 <br />DM <br />o <br />343 <br />DOOt <br />0018 <br />o <br />W <br />Bole- <br />0� <br />loo <br />�j <br />2NorrRCRA Hazardous Waste , (P.P.E Debris W/Tmce Gasoline) <br />DM <br />r <br />P, <br />352 <br />3, <br />4, <br />14 5 e Peat/ 1am A&!tr7ud Infornalim <br />8b1) Prefile! 64763 UE Jab #4153 <br />9b2) Profile #647e4 <br />wear Proper P.P.E. When Handling - <br />1S 6ENERAMR'SIOFFERORSCEUFICATION:Inanby6eclen mow rodanb oreiYmrolgrtrn[aefWry ndeev deeoNad �v+e by Te Proper shipping name. and are dasOad, wkapBd, <br />mead and YbebNplararded, and ere Neb,eppcM N WOW oondeonnr penpal a000rdng m.,,1..b6 truarmmmla remreI garenureri®I reguwthns.Nepan awpment and I em Ole Primary <br />Exporter. I w* Net em ombmY or the aalalgemen mnMn 0 Me INma or Ne eeadmd FPA adoo dedOn11n1M Can <br />l altry Not Na wean nbnlmtrntlpnemmmem BBntlAad In/0 CFR26221(a)(dlem alepaguanllryganBmta)a )(I eamm gwntlly pe�rrebOY We. <br />Month Dar <br />lot 14g ag <br />to lnYrMlma nlpmenb <br />ImPan bU ❑Expaf flan U.9. @e etlb <br />Treimpormr elgneWm (7u export oNy)' n <br />17Treoaoaur nl NRMNoildalalaig <br />_ <br />spanert ems algreWm GM) DNear <br />nn n a1M Srymbn wrN y YPer <br />C <br />H <br />Das <br />ito <br />tifa 01svepency In ;MOOn SPad ❑ ww, ❑Typ ❑P.Swt ❑P.URaacg.n ❑FA ReJeerpl <br />Mekr�Ref,. Num , <br />19b- ka mere Faddy (or Denemtor) U.S. EPA IO NumW <br />U <br />sal <br />FarEba Pilon: <br />W <br />1&, Signature orAlnmale Fadlty(or CS rV*W) MwiN Day Year <br />H <br />19. Hatardme Waste ROPM MenegemeN M[Nod Coda (Le., Code for hanadc a e=a baserem, ds rA. arm recoliM ayumm). <br />4- <br />20. Designed Famq Omer or OPanbV. Cerbdndon @ rwelpr of hazardous m Wail weed b7 ba m nff m eampt an nand In Imm 1M <br />i <br />Nam Sl9rm Monty My rear <br />— - �— O/ <br />FPA Form 81*22(Rw.3OS) Pml=vditknsare obsden_ ESIGNXtEO F ON STATE (IF REQUIRED) <br />10270.1728 <br />