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i <br /> Please paint or hPe. S <br /> FonnApproved.OMBNo.205D4GN <br /> UNIFORM HAZARDOUS 1.feneralaiD Number 2.Page 1 of 13.Emergemcy Respase Pbw 4 DOW Tfwft Numbsr <br /> WASTE MANIFEST CA2990090002 1 92 05 019 4 5 5 8 8 JJ K <br /> 5.Gerwabfs Name and Mal Address Generabre 5%Address(11 MbM R I=md"KiMats) <br /> L�+tlmm rr,�« M Lab SM 3W 40�d U6 WEE Lavo ce U„a,,m Lab S tt 3W an babes d V5 WV l <br /> PAL 80 M/L-786 UNNMM CA SIMI Ctlrral Fbbw ib�dTrary G aJ6376 <br /> GeneraWs Phow 925-422-19S AT M <br /> 6.TrargwWr I Company Name U.S.EPA ID Number <br /> TI+S "Maw ThIfflkCa mawma n <br /> T.Tramsporter 2 Company Name U.S.EPA ID Number <br /> B.DesOuded Fadlty Name and She Address US.EPA ID Nmrber <br /> OAn Hub=Cdh%L LAC 3M H OM n Colt LA 71417 EA=10%791 <br /> Facill t Phone: <br /> 9a. 9b.U.S.DOT Desaiptim(eft PMW 9409 Name.Hazard Oak ID Number, 1a.Canrakrers II.Tow 12.Ueit 13 Yyaala C.adas <br /> HM and PKkkV�P{B amyl) Na Type am* 1M m. <br /> o t Wes,CB Mom„RNM W=6 OILM D[ENS 1711 DOM38141 1 OF io P Dom DOOR <br /> 331 <br /> 2. CUWC%^wIld VIM ORM-D[ENO 1711 Dor01=62 1 DF 7 p Dona Door <br /> 2 <br /> 3. <br /> 4. <br /> 14.Spada)Handling Irashudm and Adffifim l Inhxmanon <br /> Eniter,N, .RWW92"23-�Cmitnt num U.M.EmlarWM Dom. Lid A oaXWL S*Doc ft& ,T 9 <br /> 15. GENERATOR'SKffERO"CERTIFICATION:I hereby dedere Brat the wrderda d this aaWp..mm are tiny and aoarratety desaied above by the proper ddppkq name,erd are dawned,pad®gad. <br /> marked end landedfpla=ded,and are in an mvtpeds in proper aondnan for transport a¢nrdeq b appiwhle Intermatlonalmd mandril gaymnmetW regrdstlarra.Nexportt4wat and I am the Prkrrary <br /> Exporter,I oedty tlrd pro aw4enh d Oft omWgnmerd cc I to dw tenrrs d the aBaehed EPAAdmmudpod or Cool mL <br /> I oerny that the waste minkniratkn alataarmt Iden9{fad ki 49 CFR 2B2.2T(a)pr I an a large gran*gawaW ar(b)trI am a amen t, <br /> Generabrs101lm&s PrWmYTyped Name 5lgnahrre Yew <br /> Scott A.Graham on behalf of NIA JJA 1 /7 Lt <br /> I&Intemabmd sm"enls ❑kw to U.S. ❑Expdtfmm U.S. Pdtorerdryrerdt <br /> ? Trarapdter siprrahae(gar exparts ontyk Dale bavkrg U.S.: <br /> a 1T.TransportarAd mMedgrrrerd of Recut of Males <br /> Trarnpolter 1 Pdnted/fyped Name Sign Akft Day Ulm <br /> R l4gnaer- I -% 2- f <br /> TWL2 Signahxa Day Y <br /> 18.Oisueparxy <br /> 1 Ba Discrepancy Irdiration Spare El ❑� ❑Redim ❑Partial Re(ecUan ElFW Re)edlon <br /> Man"Rebtawe Number: <br /> 1W Allemate Fealty(a Generator) U.S.EPA ID Number <br /> v <br /> U. FadWs?hane: <br /> 18c mofmarrrawFaau(Of Generdd mart Day Year <br /> H19.Hazarddts Wasle Report ManapmneM WOW Codes a.&,oades for hw loos waste treatment.6aposal,and MCI&V ) <br /> 17 Ui 1 2 kAl <br /> 3, 4. <br /> Desq/nafed'�/FacRly Owner ar Operator:C hwwuWbythe*tlp0asrledlnIleTfBa <br /> Rkfdqypad Name <br /> EPA rmt 6700.22 Rev.f2•f7 Peva eddn tea DESIGNATED FAGUff PPASB+ FO SYSM <br />