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<br /> pe. 1Farm assigned for u:;as an elite 12- Itci, ,ypewrftet - Form Approved,OMS No.2050-0039
<br /> 9 UNIQRjti HAZARpOUS 1.iGenera!ar ID Number Z.Page 1 of 3,Emergency Response Phone d.Manifest Tracking Number
<br /> WASTE MANIFEST c A ?fir 0 0 0 1 6 2 S*`0 a I0 .. J dQ' 424-9300 1JJ K
<br /> 5.Gone�fwre�T}to�r1N♦1Name
<br /> hhend
<br /> bbMelGllL�I A�dEdyretl'E' ' Gensr3ttcrs Stto Addrese(if different than malling address)
<br /> STAN f VRIJ ^�i� ' ':pct."1
<br /> 3W)AUT0 PLAZA
<br /> MOY CA 9537!6
<br /> Generator's Pllona: 20A P-36-4821
<br /> 6.Tmnsper'er 1 Company Name U,S,EPA ID Number
<br /> URY ENVIRONNENTAL SERVICES C A D 0 2 9 2 7 7 0 3 6
<br /> 7,TYanepdrfAr7..'CdrnpdnyNaYfd ; U.S,EPA ID Number
<br /> 8.Deslgnmod Faculty Name and Site Addmf!a U.S.FPA ID Number
<br /> DENuENNO F KEKERDOON
<br /> 2WO N.CG1WTON DA ST1aI ET CA 9 h
<br /> Faclll 's Phone, 010637.7'100 r C A T 0 8 0 0 1 3 3 6 2
<br /> oa 9b.U S.DOT Description(Includinn,'ropdrShipping Name,Hazard Class,ID Number, 10.containers 11.Total 12.Unit
<br /> HM and Packing Group(If an)) 13•Waste Codes
<br /> 1 No. Type QuantityWt,Nol. j
<br /> d \/
<br /> WASTE FLAMM11 i,E LIQUID, NAS. (GAS,DIESEL,3,UN 1960, PG III r� � 01001 1
<br /> DM ��
<br /> a 2.
<br /> THIS"I STREAM HAS BEEN QUALIFIED
<br /> 3. {, AT-THE
<br /> DeMENNO)KER000N FACILIT`! IN COMPTO ,
<br /> RIMA.THIS FftCll_ITY BIAS THE NECESSARY
<br /> 4, f' r
<br /> I'CRMITS i'0 RE= =
<br /> QuAI-IFIUI OIIR k_PA I'1l.1fv10f i� IS CAT080013352 --
<br /> P rtlon
<br /> 14.S oafal,Haddllnpllnatrucllanannr{Adriiflnnrtl InPon„ a
<br /> ._
<br /> NAERQ#AB1 1 128"PROf9LE#98'1
<br /> 61VS, DIESEL PO•>�A110088918 �P�QI�P[I�t`f'E
<br /> „ � �� 0EF(S0NIL"Pg01'EO7l1IE _
<br /> EQlll'PE►+EIVT
<br /> 15. GENERAT'DR'S10FFEROR'S CER711FIilATION: I hereby declare[hat the content Of the conslgnmOnt are tu'lly and accurately descdboJ above by the proper shlppfng name,and are c1assi0ed,packagod,
<br /> marked mfid labeind/p(acarded,and ern m all respects In propor condition for tranaocrt according to applicable International and national govemmontal regulations.If export shipment and I am the Primary
<br /> Exporto 1I rtlF that the contents of thu :onslynment confon 46 tt�e terms of the attached FPA Ac'oi*edgment of Coroant.
<br /> I ce Ify the th�BtB fmizatlor etawmant fdonllRod In 4 W,232.27(a)(If I am a large quant ry generator)m(b)(IfI am a smal quantity generator,is ln!o,
<br /> GenOre s/OiMmdr a 3k rt a Month Day Year
<br /> ail
<br /> F 1a;Intemntlonal Shpments
<br /> z 0 Int yr in 1.1.5. xpert from U,S, Por;of ortry/ex1C
<br /> Transporter signature(far exports only): Date leaving U.S.:
<br /> w 17.Transporter Acknowledgment of Rempt of hiatedals
<br /> TranapoRer 1 PrintedfTy ed'Nttmo +
<br /> O 7 / / Signgtur6;/-1 MOMh Day Year
<br /> Transporter 2 Pn ntedlTy d Name �aigre
<br /> Month Day Year
<br /> 18,Discrepancy ff��
<br /> 181,Discrepancy Indication Space Loantity Type LJ Raeldue ± I
<br /> ❑Paraal Rejection I,I Full Re)echen
<br /> 1 fib.Alta Uanitest Roference Number
<br /> rhate Ea�alily(or Generator)
<br /> .,,, *•.x F.,,, .-o. r U.S.EPA IQ Number
<br /> A
<br /> -aL .. .. ...i r, 't'''• Vc'. •n,i.,x.rye.r' •qtr>: ,•
<br /> Facilltys Phone:
<br /> LU T9c.Slgneture of Al
<br /> Facility(or Gsnsrefir)
<br /> Month Day Yoar
<br /> 19.Haznrdeae Woixte Report Management Melnod Codes(Lo„codes!or Hazardous waste trsnhnon6 diaocsal,and recycling sy lama)
<br /> 1 2 3' 4,
<br /> 20.Des gna ed r ditty owner or Operamr:Cerlirk:ntlan of racefpf of hazardous materials covered by the manifest except as noted In Item 181
<br /> ArM
<br /> d Name 5lgnetu
<br /> Month Day Year
<br /> E2 k -p ) OIIS edition,;are�sola�te. � 1
<br /> D SI TED FACILITY T GENERA R
<br />
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