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Falco Approved.OMB No.2054-S039 <br /> ,so print or type-(Form designed for use an elite(12 gllch)typewriter.) 2 page 1 of 3,Emergency Response»wne 4.glaniEestTracking Number F <br /> rmkof <br /> DOUS <br /> i,Generator Nember 0174�S C�72 JJK <br /> sr c,�!C C ?s 0 7 ? o�) } �°3€ ; <br /> ndMaitingAdd ress Generators 3itaAddress(ddifferentihanmailingaddr�ss} <br /> i <br /> TR Rid STREET ;i ���s t 1-401-SOUTH C;�r 01hrL LPt4r— a i <br /> I�t.�ri;r�i'i I4 071 <br /> Generator's Phone: 200—165-017 5 U.S,EPAIDNumber <br /> 6,Trarssporter 1 Company Name <br /> CAD028277036 <br /> ��1ORLI�n,L PV1P�0i�lP:1€Pfr ii 1;V1CS U.S.EPAft)NumUer <br /> 7.Twnsporlor 2 Company Name <br /> U.s.EPA ID Num <br /> 8.Designated FaeililyNamo and site Address a <br /> hSEUi;Y E14VIR01gIk,IE1ALSERVt='E_CERES <br /> 1.92fjltORGANRD. <br /> C ERRS Cf, 95358 <br /> Facifit�s <br /> i0.Conlalnem 11-Tow 12,Unit 13,Waste codas } <br /> ya gb.U.S.DOTDoscrsplion(urcluing d'mg ProperSt Name.Hazard Glass,(D Nwulrer, quantity WWoI. <br /> and Packing Group(if any)} Type <br /> 1 Evert-iRm4k HAZARDOUS WASTE,LIQU10(OILS:iii]ER) q0 <br /> TI G <br /> 1 <br /> 4. <br /> iti.Special Handling Irsshuclions and Additional Infomration <br /> �iviER�; itiwi'[f?iliAi;�:L'>i1 €11TR1=C 600 -;2�93r—io OESTERMINAL;CEP SCoe *APPRt�1RINTEPFPSs?I,ff;LPPtiXECCI`1E <br /> EQUIPMENTY EPA ERG01CY CONTACT CHEW1 R,EC 800424-9300 � <br /> proper skipping name,aid are clasafred,packaged, <br /> 15. GF1lEi;ATtJR'SJDFi ERQR'5 Gs RTIFICATIDN:1 hereby declare that the cog1prils of this runsl9nmerrt are fuNy and aocuralely despib �°9eb71 r guialians.if of t shiprnerrt and l mn>he Prima+y <br /> marked and tahetedrplacacded <br /> aware in all respects in proper condition(oflraneportacootding f4 appficablo tnlamationatand na gay <br /> Fxporfer,l celufy that iha cutdobs of this c Ariment confixrn to tno fauns of the attached uanbly erer g or b(di am n Y Stu)�true. <br /> I certify that the waste "" meat identified In 4i1 CFR 26 a)Cd am a lasso gvanbTy generator) (} monlh Day Year <br /> Signature ? <br /> Genefator`stD tarots Prinfedfiyped <br /> Iv,�t,r t _ 1 <br /> I' <br /> i6.Intematioaa shipmenlS ❑EVortlromU.S. Po (exit <br /> ❑Impodto U.S. pate k ng U.S <br /> z Transporter signature(for Worts MO).' <br /> � <br /> 1 of Raceipt of Materials M oayr r 17.Transpoder�'n <br /> � s e <br /> 7 t 1 Pr:n edit Nance <br /> Month day Year <br /> rarrsparter2Pdat. yped Name <br /> 5 re <br /> Ile <br /> 18.Discrepancy T�1 <br /> T <br /> 18a_Discrepancy Indication Spaea Quanhty ype <br /> Ra�due L_t Padlal R0,-11M 11,101w <br /> Manifest Reference Number: U.S.FPA ID Number <br /> i8b.lUiemato Facility(orG7eoemlor) <br /> tdi Facrlttys Phone: Month Day Year <br /> B 18c.Stnaluro afAitarnate Facility(or Generator) <br /> d <br /> zs siems <br /> 19.Hazardous wale Report Managemenl Method Codes(Le.,codesfot hazardous waste treatment,dtspasal,and m4ding Y ) 4. <br /> ca <br /> z8.Designated Fadlity Omar or Operator:Cerhgcaifon of FAc*tot bazardous matelots caaered by lhem$���eceptas Octad in Item 18a htonlh pay Year <br /> Prinledl;d Name <br /> 22( iionsareObsolete. DESIGNMED FACILITYTO DESTINATION <br /> cPAFor187U0RSi�T�{IL;]a14ClUIR1=R} <br />