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Please print or type.(Form desi o for use on elite(12-pitch Ater.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAD99OU73ti8 z Uni r USA Inc- 009 <br /> 09 800877 FLE <br /> S.Generators Name and Malty Address GenerebsS 11153 Re ress(' ererd than mining address) <br /> GR CA"E NTSR CO GR.CARPPNTL-R Co <br /> PU BUX 279 171008IIARLAN RD P.U.BUX 27Y <br /> LATT(RUP,CA, 3 I.ATIIRUP,CA,95330 <br /> Generalots Phone: 'i-,"s2�sflo <br /> 6.Transporter 1 comparry Name U.S.EPA ID Number <br /> UNIVAR USA INC. CAD010925576 <br /> 7.Transporter Company Name US.EPAID Number <br /> LNOLUND EQUIPMENT CO. AL,D9824035R6 <br /> .Designated Facility Name and Site Addres U.S.EPAID Number <br /> U%13VOLOt7Y BGATTV AI`.'T3318)118N8) <br /> PO{�60��X.'+7%,HWY 95(11 MY S OF BRATTY)% <br /> FBAtllity s PMne?N V,89D03-1157 <br /> 1941 1 <br /> gar 9b.U.S.DOT Descrow(including Proper Shipping Name,Heard Class,ID Number, to.Containers 11Total12.Unit 13.Waste Codas <br /> HM and PaoAe g Group(R any)) No. Type Quantity W.Nal. <br /> 1.Nan-RCR A Harardmr,Waste,Solid((til and Abscxtbent) To 7 <br /> - - ---- -- <br /> 223 <br /> FU 2. <br /> eueue <br /> 3. <br /> I <br /> Lli <br /> 4. mffi <br /> I <br /> 14.Spe sial Handkng hshuctons andAdditiortal lydormation <br /> I. 070128300-1507(0)T.AND ARSORARNT) DEPARTMENT <br /> PLACARDS PROVIDED BY THE CARRIER/S1II11"PUR YUSINO DRIVER SIGNATURE <br /> •s 'PR CALLER MUST LI3F.NTIFV UNIVAR USA AS RPOISTRANT(CON-MAL-1`497569}"w• <br /> 1S. GENERATOR'910FFEROR'S CERTIFICATION:I hemby declare grAthe ommems of this consignment are furry and accuraNdy described above by the paper stepping name.and am drissRed,packaged, <br /> marked and labeledlplacarded,and are In All respects n properconaition for hams according to applicable elamefona and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,Ica*that the contents of this consignment confirm tothetarms of ft altadred EPAAcknoMedgmam of Cansenl <br /> I teddy that the waste minimization statement identified In 40 CFR 282.27(s)If I am a large quantity gernumv)or(b)(9I am a smed gsndlygeneretor)is am, <br /> noretofslORarafsFrffftdn Name MonfinY year <br /> N771 n1 I /� 1 -31 -7 i /7 <br /> 116.International Shipments <br /> F- ❑Imporlbu.S. El Export ham U.S. Porlof emryfexR <br /> Lan ti nature forex oro : Dae leaing U.S.: <br /> W 17.Tr porWAO.h6MOdgmeolof Rece0ofMatadals <br /> rammolar l Pnimedffyped Name Signature tenor Day You <br /> i CQ � 3 -7 i <br /> Thmspoder2 PdnieMyped Name re orm my Year <br /> 115 <br /> 4. 18.Discrepancy <br /> 18a.Discrepancy Indiaton Space ❑ Quantity ❑Type <br /> ❑Resitlue ❑Partial Rgec9m FW Rejection <br /> Manifest ReferenceNumber <br /> sem„ 18b.Alternate Facaily(or Genemtor{ LLS.EPAID Number <br /> 7 <br /> U <br /> 6 <br /> LL <br /> Facilitys Prune: <br /> W lac Signature orAlmmale Faulty(or Generator) MmN Day Year <br /> 2 <br /> 19.Haz edous'Wasle Report Management Method Codes(o.,codes for hazanbus wase treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Opembr.Gedificabon of receipt of Is7emoue materials covered by me manRestexcep as noted to Rem 18z <br /> PdmediTYped Name Signature k4oft Day Year <br /> EPA Form 6700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILIT Y TO DESTINATION STATE(IF REQUIRED) <br /> OnlerfrU 41671 W, <br />