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41 <br /> r ease`pndrir type.(Form asigned•(or use on elite(92-pbh)-pewnter) - <br /> Form Ap roved:OMB No,2050 0039 <br /> Generator ID Number �2.Page 1 of 3,Emergency Response Phone 4,Manifest Traeking Number . ( �[ <br /> UNIFORM HAZARDOUS 909-M9�5W7000250478, y�f� " <br /> WASTE MANIFEST C Qt ❑ 9 .8 2 5 0 8 5 '. <br /> S.Generator's Name and Mailing Address , __ Generator's Site Address(if d8ferent than mailing address) <br /> Undled Wes n Gr ens <br /> Ath t:Pat GtA�i ITIAt1/'5200 Sheik SWJn et 1990 R Crd Rd- <br /> C.*�nuTler>Ce CA 90a4D Stockton CA 96215 <br /> Generetofs Phone: — U.S.EPA ID Number <br /> 6.Transporter 1 Company Name 11 <br /> Haz Mat Trans,.[no. : C.A' T: 0 8 0 0 7 :.2 8 0 0 <br /> 7.Transporter 2 Company Name' <br /> U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address <br /> U.S.EPA ID Numher <br /> Crosby Overton <br /> 1630 W. 17th Street - I <br /> Long Beach CA•9D813 <br /> G-6 d 0 '2 k 0`8 01 1 <br /> Faalitys Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Cohtainers 11.Total 12.Unit 13,Waste Codes'.' <br /> HM and Packing Group trf any)) No. Type Quantity WtNoL { <br /> 1' UN 1956,WASTE Aerosols FM D001 1 <br /> o X 2.1 [3M P { <br /> . LLr .- <br /> 2 <br /> C�7 �'It:R Lip WAM T/AI PECEr Ep,HAND=AND STORFp R1R S E]Qii 1M <br /> DIJMn4!„1NBATMIZNT OR REUSE CROSEY t OYFR7c�ty,INC,OPEAATFS <br /> x�, PEIehS LtAIL aSTANCE n�rxot. <br /> 3: <br /> k' t T11R IINVIRt)NMf N1 AL FRtl7Ty('1 i01Y 1CFN M ACCORDANCEµ71l! PrtOV15p QP <br /> 1719 WOURCK CGNSC1IWATION AND RRCOVE�V AVT:OF 1974.TQGE *.X wrIIl,App��A 4 <br /> -1TDKIL4., AND STA1M tiROUtAT1ONS, CROSBY R OVEi HAS 41.1- o TifB tVEt�SS <br /> rtltMITS TO ACOR Tltlt R8F6RSNC1 ?WASTE Y <br /> 4. <br /> atlon I <br /> ilio a <br /> I Inform .. .' <br /> Handling <br /> lnstructla <br /> ns,and Add n - , <br /> 4 dal Ha , <br /> 1 .S <br /> Pe <br /> n9 <br /> 6e''GO 298 <br /> aerosols- Prafile5T192 ' I �f G]aves: qg <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this oonsignmeni are fully and accurately described above by the proper shipping name,and era classified,packaged <br /> marked and(abeledlpiacarded,and are in all respects in proper.condition for transport according to applil6ble.intematonal and national govemmental regulations:If export shipment and I am the Pdmary <br /> Fxporter,1-certify that the contents of this consignment conform to.the teens of the attached EPAAcknowledgment of Consent: '<' t <br /> I certity that the waste minimization statement identified in 40 GFR 262.27(a)(if I arra large quantity generator)or tb)Ql am a small quantdg generator)is true <br /> Generator sl0ffe s Printedfr d Name Signature Month Day Year:. <br /> r 1 <br /> 16 Intematin I hipments. Import to U S 0 Export from U S .Portof antryfex-R: <br /> Transporter signature(for exports oniy): W;"Dais leaving U.S.. <br /> W 1T.TransporterAcknox4edgment of Receipt ofhMatenals o- <br /> Transporter 1 PrinledGTyped Name Signature „ Month Day Year <br /> O N <br /> a , <br /> z cans er Pri yped Nama ign on flay <br /> ~ 18.Discrepancy <br /> 18a.Discrepancy I¢dication Space': Quantity. Type 0 Residue Partial Rejection Full Rejection <br /> - .. - -- <br /> . r•.:Manifest Reference Number. r ` <br /> eneratos U,S EPAID Number <br /> 18b.Altemaie Facility(or G ) <br /> J - - - - y <br /> 1a Facilii�s Phone: - - - - <br /> 18c.Signature of Alternate Facility(or Generator)Lu <br /> Month _ Day Year, <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(1 a codes for hazardous waste treatment,disposal and recycling systems) <br /> Q <br /> ]4. <br /> r,r eraty <br /> r.Certification of recei of hazardous materialscoveredby the manifest except as nd in Item 18a " <br /> Facility deme o <br /> " Hated Fara <br /> 20.Desi <br /> 9 tY <br /> Signature �- Month Day.- .-Year <br /> PdniedlT mem <br /> • ,, <br /> E orm 8700-22(Rev.3-0Previous editions are obsolete. f DESIGNATED FACILITY TO GENERATOR <br />