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. )t LLNL-AR-808080 <br /> U0 wLease print or type. - Form ApprovW.OMB Na 2051]-0089 . <br /> UNIF6M HAZARDOUS 1.tseneralor ID Number 2.Page 1 of 3.Emuprvy Response Phare 4 MvWsdTMcMq Number <br /> WASTE MANIFEST M890090 z 1 19254234; 1 019 4 5 5 8 8 JJ K <br /> S.Gonarahr's Nana and Mam Address Generalota 58aAddrasa pf d8faterA ftm ma ft aMmn) <br /> Uwlem a UomlilmwliadmdLabSft3WcmbdoircrUSWM lawr M Utre MOM PIRMI,oai Uab Skt 300 an bdMdf d U6 MWA <br /> PAS&X=/Ir73li UJwlmrosaCA94551 Comd Hdlom RoadltacyG1s6376 <br /> Genambes thane:935.422 lM ATTIC <br /> 8.TmmParter 1 Company Name U S.r:PA ID Number <br /> Tri-state Maur Transit Ca MOD N5038M <br /> 7.TrwapMter 2 Company Name U.S.EPA tD Nmnber <br /> 8.Da Vs3W Fadity Rama and SRa Address U.S.EPA M Number <br /> CMm Harbm Caft LLC 3763 Hlpwy 471 Cdfaft LA 71417 LAD90035M <br /> FacMft Phone: <br /> 9a. 9b.U.S.DDT Desaipimn Qndr*y Proper 5i1p11 9 Nam,ti®rd Clens,ID Number, 10.Canwrws 11.T w 12.LM 13 � <br /> HM ^p P P(ff any)) Na Type WLAW. <br /> c t'Wtlts�,CriMdM small MM ORM-D[ERG 1711 DOMM-1 1 OF 10 R 0M Dw <br /> 331 <br /> IN 2'Wbt%CE MCOM MM�ORM-D[ERG 1721 DOM38A-1 1 DF 7 p OM D= <br /> Z <br /> 3. <br /> 4. <br /> 14.Special tixW"Instirrctlarrs and Aditnal Infamwbm <br /> Fly Ph0w925-423-4M olIct game i1.13i.Fjn8FlGMY DlsPdft toad#MM-ft snip Doc Mas"� lT 9 <br /> �nrrce rdest3e nNnbaft i]lE o� an i�rtroice. gp02927611,gpo3oo�s �t57�Ybb <br /> 15. GENERATORVSgffEROR S CIIfTIPICATION-.I hmbydedere bstfie camtenh of rids rm Ig mrenl ata fuly and awur"dnabed ebm by go pmperaNppkg rww,and are ale5ett4 packaged, <br /> marked and tabaradoaamded,and are in as mg*ch in proper owdOw for t weW acwr 5 loWu InWnwi Wand nelonsl pararama=rerA*m.r wq art donerrl and I am W P&wy <br /> Evorler,I ce"that tte earderds of ft oonatgmrent wham to the h m of the alladr I EPAAdmmw6dgrrra4of Canard. <br /> t m*that Bre wash minknWidm stakment kenfi8ed in 4g CFR 28217(a)(M I mn o Wpa gmft yp erstur}ar(b}{ip am a amaA )h <br /> GomratohlDlkmes Nktedffyped Name Slgnabse MMM Day Year <br /> Scutt A.GMhM on btll M of NIM I 1 17 <br /> 18.Irdern ftw Shipmerds ❑k w to U.5. ❑Evw from U.S. Port of w*y*t: <br /> i Trmuporiar*Mbae(for exports anN) Dale Wa*g U.S.: <br /> 17.TmnsporlerAdmoMA AFF t of Reca0cf Wedeh <br /> Transporter t NnleCyped Naps Mara Day Yaet <br /> All 4'n ae Ve <br /> Thk �. <br /> 2 Mmlh Day Ydkr <br /> I&D&mpxy <br /> 18a.Dbw pwz7r krdrafion$pace ❑ 0"k 117* ❑Residue ❑Pardef R*a, ❑Ful Reiec6m <br /> Mwdled Refarw Number. <br /> 186.A[temats Fw ty(a Gamester) U.S.EPA ID N tuber <br /> V <br /> u- FaciHtls Phone: <br /> M Slpaaerrs of MMUle Fadity(w GenerYor) MarAt Day Year <br /> N19.Hazanfoua Waste Report MwmgemeM Method Caries p,e.,wdes fw haardars waste trw*mnk dapmal,and mcy ft sp ien) <br /> � 1. - / 2 3 4, <br /> Designakdd F aMyt7iMw or Owalor,CertlWm of receipt of hmwd=rrrarriah wnW by the as rrded h 83 <br /> PMMYPed Name <br /> EPA rm s7Do-iz Rev.i2-M-PriWowedHd=amobsAfe. DESIGNATED F TOEPRse-MMKIFEMYSTEM <br />