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l 1= Please pnnt or lyse. (Form designed form on elite (12 -pitch) typewriter.) <br />DISC. 00070.'2325 <br />FormApploved. 0M8 No. Z0504)IX19 <br />EPA conn 5700-22(Pw 305) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REOUIRED) <br />10540.2260 <br />UNIFORM HAZARDOUS 1. Generale, 10 Number <br />2. Pegg t of <br />3. Energen Response Plane <br />4.MmftgTmckngRWdm <br />WASTE MAN6E5T CALM336993 <br />1 <br />(MR)467-0188 <br />000782611 <br />JJ K <br />5. Generator's None and Making Address Gene2tafa Site Address (if clearers Nan makng address) <br />Oakland Bag <br />635 Aarore Street <br />Stodeton, CA 95203 <br />Generators Phone: 467-0188 <br />S Translator 1 Company Name <br />U.S. EPA ID Number <br />Brlatell 6rcionmernal Corp <br />CAD982434M7 <br />7. Tiansporer 2 Company Name <br />U.S. FPAID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPAID Number <br />Crosby & Oreton <br />CAD028409019 <br />1630 West 171h Street <br />Lanq Beech, CA 90613 <br />FKE Is Phone: <br />ge, <br />Go. U.S. DOT DesMption[evfudng Roper Shipping Name, Hazard Class, ID Number. <br />10.0arnainers <br />11, Total <br />12. Unit <br />13 Waste Coda <br />No. <br />Type <br />MM <br />and Pead, g Gcup [dano) <br />Ouankty <br />WLNol, <br />1. <br />ne <br />0 <br />)f <br />Wast Prirrtrsg Irdr Related MaWrials, 3, LI <br />DM <br />G <br />13001 <br />212 <br />214 <br />1 ibPGII— <br />o�q�9 <br />0 <br />NON RCRA Hazardous: Wast, Liquid <br />DM <br />S <br />3 ^ <br />G <br />34 1 <br />3. <br />4. <br />14. SpKW Herding Insbuostona and Addidmtl Irdarmafion <br />Wear Appropriet Personal Protective Egsipment <br />1) 70531 <br />I 1 I I <br />15. OENERATOR'SIOFFEROR'S CERTIFICATION: I hereby tiedera that the contents of this bonslpment em ely and soorraely desmled above by the proper shipping rerre, and era dasUNed, pacMaged, <br />marked and Iabelellperarced. and en n ell respects In proper mndtion for banspat according to appecable Nlernational and national govemmenel regulationsd export shipment We I am Ne Primary <br />Exporter, l costly that the mntane of this bonslgrmeM mnbrm to the Mme of the attached EPAArknovdedgment of Consent. <br />I cuff thus the wade minin4aton statement Wended In 40 CFR 28227(s) (e I am a large quantity generaM) or (b) (dl em a erred quantity gene+ Is true. <br />arebrY rurk.lorm Rypod <br />monet DAY Year <br />G.. <br />terstar <br />tcovid bropments ❑Import to U.S. ❑E>W ham U.S. Pon ofentryfedt <br />Trangthi elgnabn (M osmore 01I Deco Will U.S.: <br />17. This repowWeAdoroMrna of Receipt of Me <br />edgrd ese <br />T i 7MWTypd Name n <br />2 <br />T 2 yprq None $IpneN <br />Mi <br />�. <br />pq <br />to. Discrepancy <br />9F.IRejadm <br />iIse. <br />Discrepancy Inds Spam ❑ a." ❑TYP Resdre <br />❑pow Rel000n <br />Mammal Reference Number. <br />18b.Atemae coolly (or Genmace) <br />U.S. EPA ID Number <br />V <br />LL <br />Faraey's Phone'. <br />1&.$ignaWe of Attenuate, Feolity(or Generator) <br />Month Day Year <br />QW <br />2 <br />y1S <br />Hazwdm Wass Report Ma wroard Method Codes (i.e., booksfor hazardous mass treaMent disposal, and recycling systems) <br />c <br />7 �A vi <br />z. 9 k ]. <br />4. <br />2D. Designed Facility Omer or Operator: Complication of moto of hazardous maeMh covered by Ne manNest except as noted In lam lee <br />1 <br />yped Name �pria�e <br />vrc. �i�h 5 <br />Month Year <br />�p �) <br />V 1 Z <br />-a� rYC c. <br />V—i <br />EPA conn 5700-22(Pw 305) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REOUIRED) <br />10540.2260 <br />