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Please print or type. (form designed for use on elite (12 -pitch, writer.) <br />UNIFORM HAZARDOUS 1. Generator ID Numb,Qr <br />WASTE MNAaNIFEST�a <br />5. Generart�iN t mend•.rTt�i.d �e TG1 i'N <br />1521 WE'31 CHARIER WAY <br />T 0CK T r, N C� � ? <br />Generator's Phone: 209 M- <br />6. Transporter 1 Company�Name <br />ASBIJK� E'WRONNEN AL SERVICES <br />7. Transporter 2 Comoanv Name <br />k-_.., <br />Generators <br />different than <br />Form Approved. OMB No. 2050-0039 <br />fest Tr c ng Number <br />JJK <br />C A D 3 2$ 2 ? 1 0 3+ <br />8. Design, I'ty ap�e1 U.S. EPA ID Number <br />, t41A14Z K 9�VN <br />2= N. ALr'MDA STREET <br />.-(.',NPTCN 0 10)537-7 100 CA 9= T 9 7 <br />Facility's Phone: <br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes <br />HM and Packing Group (if any)) No, Type Quantity Wt.Nol. <br />o WASTE FLANNIABL LIQUEl, N.0 S., 3, UNI", PGII ,--, <br />U-1 2 <br />Uj <br />THIS WASTE STREAM HAS BEEN QUALIFIED _ <br />EOR RPrYCI EATMENT AT THE <br />3 DeMENNO/KERDOON FACILITY IN CO 1 <br />CALIFORNIA. THIS FACILITY HAS THE NECESSARY . <br />r <br />QUALIFIED. OUR EPA NUMBER IS CAT080013352 <br />1? special Handlin Instrucuons and Aooiuonat Inrormavon <br />"IAERN9B1 : 128"PROFILE #981 _224 ,a OkF -IIID dt3-.�J' i�0#A1iGi768t3i 'APPROPRIATE PERSONAS <br />PROTECTI`+1E EOUPNENT <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the con is of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for trjsport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms olthe attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generatoes/Offeroes Printedrryped Name Signature / , Month Day <br />—j <br />P- <br />16. International Shipments <br />❑ Import to U.S. Export from U.S. Port of entry/exit: <br />z <br />, <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. TransporterAcknewledgment of Receipt of Materials <br />p <br />Transporter yPrinte�Pryped Name ..- Signature Month Day Year <br />CL <br />QTranspo <br />2 edrryp clName " / <br />Signature`' . ' % Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ty ❑ Full <br />❑ Quantity El Residue Partial Rejection Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) + <br />Month Day Year <br />Q <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1 / 1 <br />t� <br />Li <br />2 <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printe yped Name '^ Signature _ f : _ Month Day Year <br />1 <br />/ a ' ."�.��'. rL �r !°1,•q <br />=Pd Form Previous editioKs' re obsolete. DESIGNATED FACILITY TO GENERAT09 <br />