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Please print or type.(Form designed for use on elite(12-etch)typewdtec) Form Approved.OMB No.2050-0039 <br /> } UNIFORM HAZARDOUS 1.Gen Wr ID Number 2.Page t of 3.Emergency Response Phone 4.danHeat Trackup Number <br /> 11 WASTE MANIFEST C A !- l� 0 G 4 1 0 6 S 2 ' 2 209747"3965 012296099 JJK <br /> "S.Generebrs Name and Mailing AddressAtt IlrTIBOTOGenerators Site Address(I different than mailing address) <br /> Oak Harbor Freight Lines,Inc. <br /> 3016 Lbcxrds Rd.,Sksekion <br /> Stockton GA 96205 <br /> GenembesPhone: 2 0 4 7 - 7 3.4 0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> K-VAC Environmental Services IC A R 0 t; 0 1 6 3 0 9 7 <br /> 7.Transporter 2 Company Name U.S.EPA IO Number <br /> rVLtA 1;:S Ttff-{nlIC*1- .S01_WT1JJVj � N-S�> 6 g 631361 <br /> 8.Oesigoated Fadl'rtdyr Name and Site Address U.S.EPA ID Number <br /> Veola ES Technical Solutions <br /> 1704 W. First St. <br /> Azusa CA 91702 <br /> Facility$Phone', 800) 396-6726 IC A D 0 0 8 3 0 2 0 0 3 <br /> 9a. So U.S.DbT Description(including Proper Shipping Name,Hazard Class,IO Number, 10.Containem 11.T'W 12.Uhft <br /> HM am Packing Group(4 any)) No. Type Quar" w1jue. 13.Waste Cada <br /> 1i1N1993,WASTE flarnmable lqulds,n.o.s.(acetone and petroteurn. - -7 (� 213 212 1 <br /> }� dfstilates),3. PGit.Rte(1)001) (lab pads) DIM 5 1 -•- <br /> � <br /> w X 2NA1993,Combustible liquid.n.o.s. (petroleum disliNetes), PGill tg-DM 343 <br /> P J <br /> UN1693,Bisulittes, aqueous solutions,It o.tr. t141 <br /> X8 P;pitl TR 93S <br /> 4.Ne4i-RCRA. Hazardous waste, sold(died absorbent and primer' ! 352 <br /> 14:Special Handling IPshuclrons and Addtonal Information <br /> .9b. 1)- Profile X9'c1.33 ERG 4 12P LP 7. <br /> 9b.2.) Profile K +r6161. ERG k 129 <br /> 915.3) Profile f!w o185 ERC". it 154 <br /> 9b.9i P&ufil� b. ,d.� F416-G�(pa. <br /> 15. GENERASQR'S/OFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according W applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cerbly that the contents of this consignment conform to the terms of the attached EPA AckreaAedgment of Consent. <br /> I cemty that the wast$minimization statement identified In 40 Cl 282.27ad(rt I am a large quantity,generator)or(b)(if I arm a small quantity generator)is We. <br /> r01hrors PrintedlT c <br /> yped�'/v+t - Signature �/ Month Day Year <br /> I&lnlemakonal Shipments <br /> ❑Import ro U.S. ❑Export from U.S. Pori of entryleze: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Recept of Materials <br /> srponer 1 PrintedRyped Name Signature / Month Day Year <br /> T <br /> Go la- lo <br /> Z Transporter 2 Printedrryped Name Signature Month Day Year <br /> pen <br /> 4. 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fop Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Factity,(of Generator) U,S.EPA ID Number <br /> J <br /> U " <br /> LL Facdiys Phone: <br /> 'w 18c.Signature of Alternate Faollity(or Generator Month Day Year <br /> Q <br /> Z <br /> 3 19.H Y(aste R port Marwgemant Method Codas Q.e.,wde$for hazardous waste tmatmenl,disposal,aind reryrling systems) <br /> 4. <br /> 1TR MA <br /> 29.1j toted Facility lor Operator Cgrtification of receipt of hazardous matenals covered by the manifestmempt as noted Item tea 5 <br /> K,.O L � .- rl(``\ 1. <br /> EPAForm:8700-22(Rev.3-05) Previous editions are obsolete. DE IGNATED FACILITY TO GENERA OR <br />