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:Please Drint orlvbe. ball designed far uswan alifAf42-nlddrt lwaaadrart <br />If1411f��;If�lifll�Iffllili�ffi��l# II1i�11llll�i�illliili��lllfl#�� <br />Month . Day. Year <br />DESIGNATED FACILITY TO GENERATOR ' <br />UNIFORM HAT,ARDOUS i. Generetp lD Number <br />2.PageI <br />-. Emergency Response Phone <br />4. Manlfeet Tracking lkrmMr <br />WASTE MANIFEST CAR000225557 <br />,� . 1 <br />(81_i0)-510-8510. <br />.R q <br />1 <br />5. a tor' aloe d ellin Addr�q, for t di t ' agdre - <br />V%��' .�l�tr �.�.1�. Ytf(:,`�REIOHT /JAMIE HAINES � �'�_ �� <br />��! .�i�LII{�r��i <br />i0990 ROE_ AVE 1535 E FrESCADERO AVE <br />OVERLAND; KS. 66211 TRACY CA 95304-8501 <br />( 89 0232 �. <br />,62) GEN : 41410 <br />Genaretore Phone: <br />. Transporter 1 Company Name ., _ - U.S. EPA ID Number -- <br />HERIfAGE TRANSPORT, LLC-.:TS.HAYNARD IND0584841i4 <br />7. Transporter 2 Company Namp U.S. EPA ID Number <br />8. Dealgnalad Facility Name and a Address -- - -- - U.S. EPA ID Number <br />HERITAGE ENVIRONMENTAL SERVICES <br />284 E STOREY RD AZD08i705402 <br />CGOLIDGE, AZ .95128-9205 <br />FaciiWs Phone: (520)7234167 _. .. - <br />...9a. <br />6b. U.S. DOT DiTism onIindu ling Proper Shipping Nam, Haiand CNea, D Number <br />.. 10. ConleMars <br />11: Tdel <br />12. Unit <br />t <br />13: Nfeate Codes.. . <br />No. <br />Type <br />HM <br />and PaGdpg Group (if any)) <br />Odafdky. <br />WtNol. <br />NUN RCRA HAZARDCIU4 WASTE LIQUID <br />C <br />141 <br />LC,J <br />2. <br />3;' <br />-177 <br />4. <br />.. <br />Pabuctions and Additional information L _ - <br />I. W9 0917679 1,Xc15 s s c�+G,�k DF N lr ! ivlLlu l <br />SRO 'Z?3�C3�17%�/ZGj, T 33S�Sr ERIoEMI 15035590313T <br />75.-.RNERATORrSIOFFEROR'S.CERTIFTCATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping hands, and are deasil'I padueged, <br />marked andlabelad/placarded, and are in all respects In proper condition for eanspod according to applicable international and national governmental regulators. Ifaxpod shipment and I am the Primary <br />Exporter, I certfy that the.contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent . <br />I certify, that the waste minmdraton statement identified in 40 CFR 26227(a) of I am a large quanfily generator) or (b) (al am a small qua ft - derelor) is true. <br />ere rite ams na -- By Year <br />V,�✓ i " <br />. 16 Int a at Shipments ❑ Import o U.S. ❑ Eapod U.S.. Part of .4'k - <br />— <br />TransWer signature for exports on Date leavi k-- <br />17. TrasspoderAdviowledgmentof Receipt of Materiels <br />Transporter 1 Printed/Typed Namegnature _ _ Monthay ear <br />O <br />IQU <br />y <br />._ "_.. <br />-1c <br />lmnsmawllyped Name' .- r - ear <br />.. <br />- <br />.18: Disprepan0' .. <br />18e Dhaepency Indication Space ❑ ❑ Type. ❑ Residue ❑ Partial Rejection ❑Fug Rejection <br />Manifest Reference Number - <br />186AlternateFacility (or Generalor) - <br />.. U.S. EPA ID Number <br />a <br />LL <br />FacilitysPhone: <br />Signature of Alternate Facitty(or <br />Q1& <br />19. Hazardous Waite Report Management MI Codes (i.e., codes forleiardous.wesb be*NK &Paul, and recydleg systems) <br />p <br />L <br />2. 3. - <br />4. :. <br />Hi41 <br />._ <br />- I <br />ZO. Desgnated' acity0wneror OperaW: Certification of recept o'haza rias maltriel5 mrered by"mamfestazcepl as noted in Item lits -...' _ <br />PmteMype' me SgWase <br />111 <br />Month . Day. Year <br />DESIGNATED FACILITY TO GENERATOR ' <br />