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MAY-26-2004 10:36P FROM: TO:12094683433 P.2 <br /> 'F�105-A] <br /> 'Please print or .(Form designed for use ort edits 12-pitchy pewrRer.) Form Apptoitred.OMB No.2050.0039 <br /> UNIFORM HAZARQOUS 1,Generator ID Number 2.Fags 1 of 3.Emergency Response Phone eatTaraking Number :I <br /> WASTE MANIFEST <br /> CA <br /> WASTE ©O�'T � � ,'m383 SKS <br /> -A—12611 <br /> 5.Generators Name and Malang Address Generatet's h"A'ddress(If different than mailing address) <br /> VILLAGE UeST i93R114A <br /> 6649 EMBARCADERO <br /> S`POCKTON CA 952111 <br /> Generators Phone: 2 09 951-1551 <br /> 8.Transposer 1 Company Name U.S.EPA ID Number <br /> SAFETY-}tLEEN ;Y;TERS, 10C THROGOO50930 <br /> 7.Transparter2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name end SbAddreas SAFETY-I(LEEN SYSTUTS, MC. 000616 U.S.EPA ID Number <br /> 1722 COOPER CREEIC ROAD <br /> DENTON, T9 76200 <br /> 990w 4€3;g-ti20Q `dFIDO19663 i%1 <br /> Faclll s Phone: <br /> ge, 9b.U.S.DOT DesarlpHon(inchrdgtg Proper Shipphp Name,Hazard Class,dD Number, 10,Containers 1t.Total 12,Unit I <br /> 13. Codes <br /> I'M and Paddng Group(if any)) No. Type Quantity WLN01. Wesie <br /> Ix kA:qE—Qw"'Liid - N 155 -1 <br /> #uK MASTE SOLIDS Ct]l�llANING FLAMIABLE 0€'3 P F0043 001 <br /> ,IQUID, N, 0. (TOLUENE,PIETHYL ETHYLKETONE) 4. 1 U143175 PC II (ERC#133) , D032 UTS <br /> 3 '� <br /> 4, <br /> 14,Special Handling instructions ardAddiwalInformation SK TACK#106872260 00025318590 <br /> 9B2, ERCP 13,: <br /> 15. GENE TOR'SIOFFEROR'8 CERTIFICA : I henslly declare that the wrrtents of mis m stgrxnent are an accurately-04' a by @.proper shlppdng name,and are claselnad,packaged, <br /> marked and Iabeledlplacardad,and are in all respells In propercondltion for transport aocordmg to applicable irdematlonaland natlanal govemnoftl regulations.If axW shipment and I am the Primary <br /> Exporter I certify that the contents of Ihla consignment aontorm to the leans of the aeached EFAAcknoWedgmant at Consent, <br /> I certify that the waste minimization statement Identified In 40 CFR 28227{e)(if I am a large quentlty generator)or(b)(III am a smell quantity generator)Is hue, l <br /> Gaaerstors/Offames.Pr nWTyped Name Signature Month Day ear <br /> .j is,mmawarshipments ❑Import to U.S. ❑Expert from U.3, Port of emrykxlt I <br /> Transporter signature(for exports only), Date fem+ng U.S.: <br /> 17.Transporter Act nowledgmam of Recelpt of Materials P <br /> Er 1� rlmedfTyped Name Signature Month; D <br /> Day y %ff <br /> CL <br /> Zts0rWr2FdntedJrTyp&dNaMe Nie^ Monthi Day Year <br />� 18.Dlsereparrcy <br /> R <br /> ISo.Discrepancy Indication Space ❑ Quantity ❑Type ❑Rasmus ❑Partial Re)edlon ❑Full Re)ecllon <br /> Manifest Refemr=slgLber. <br /> tBh.Alternate FacYlly(or Generator) U.S.EPA ID Number <br /> Fadfl ys Phonw, nt Day ear <br /> gneve mate a Illy or <br /> GeniarawO a l <br /> Z <br /> in19 Hazardous Waste Report Managemam Method Codes(i.e.,codes tot hezerdous waate treatment,disposal,and recycling systems) � <br /> G i. Z 3. 4' <br /> 20.Deafgnated flty Ownerar Operator.Cerdealion of receipt of hazardous materials cowered by the manifest except as noted to Item 180 -I <br /> 1 yped Name S gnature on Day Year <br /> I <br /> EPA Form 8700-22.(Rev,3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> i)t]lts�33 "1) <br /> 00?0az, 3.� m._. 4) ) <br /> I 1 }200�3z 2.iO4i4G1 0�id 2)200092D60/40141150 <br />