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316109 � 13963 Pie mVdnt or type.(Form designed for use on elite 12. tch t writer, Form Approved,OMB No.2050-DO39 UNFORM HAZARDOUS 1,Generator d)Number 2.Page 1 al 3.Emergency Response Phoma aNfestTracking m j WASTE MANIFEST CAROOM7239 (877). 577-266 0049 4 0 4 2 0 j 6.Generator's hone and MaIng Address 1f f Generators SIte Address T different than maling address) DUCT C/O.31 CONPAIT Ron DBPOT #01166 1915 AM ATEOR #111 251 CMCI ATI Ge,orAWAP CA92118 (866)451-1344 A CA'95335 219)825-3133. 6.Transporter 1 Company Name U.S.EPA ID Number 21St aMMY MVIROMMTAL MWEENT OF ILC 16&012 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated holtity Na and SIta Address U.S.EPA ID Number BURLINGTON MIROKKINTAL, W. KW FACILITY . 21245 77TH ATBNUB SOUTH F s Phone NA 98132 253 872-1131 WM91281.767 go. 95.U,S,DOT Descripilon Onciu ft Propr Shipp ng Narrm,Hazard Class,ID Number, 10,Containers 11.Total 12,tit 13.Waste Codes HM and Pecking Group Of any)) No, Type Quantity WL/Vol. t- 011951 KAM BROOLs, FLUMI, N.G.8. (Win MTh.X1T b b j D a Dell D135 331 i 0 2.1 DOT-OP12842 (11111-111#. 2. 011263 VASTR POINT PILATID W11111 3 911. R (D 1=116) � ® Dill D135 33.1 .... da�. �, F I (� 3. U12811 NAM TOXIC, LIQUIDS, ORGANIC, I.O.B. (2,4-11) 6.1 MI DIN . Dili 331 X 'TOXIC' RQ(Dlli4I) (3 a j F ®o p 4. WTI CON031 LIQUID,- BISICF INOMIC,_ I.O.S. { 12Z <3 X R XIDB, PO SIUR 1YDROXIDI) 8 PGII R!( 2$1 ) f3 d I ,aF 00.20 P 14. c i a Instructions and AddWortal Information U 5-S I X (1) 2.1-13 (126) 111OBOLS (2) 3-13 - BRG(121) FLMULS LOOBIRCI (3) I ML-63 - BR10(153) TOXIC (LIQUIDS OILY( (4) B BB-14 - (154) AIMBICORPOSITI LMPGBAL#'l 15, GENERATORWOFFEROR'S CEMICATION;I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassifted,packaged, marked and labeledfplacardod,and are in 0 respells in Proper condition for transport according to applicable international and national governmental regulations,9 export shipment and I am ttre Primary Exporter;I cerdfy that the contents of this con4mentoonform to the terms of the attached EPAAeknonleOgment of Consent. I certify that the waste mW ndza*m statement idenBNed In 40 CFR 282.27(8)Of i am a targe quantity generator)or(b)Of I am a small quantity generator)is true. GeneratorsfOBer�dnle�dNerye, � Sigrreture Month Day Year tit.✓✓�y�'A'�''�� 'I i v 16.1nisma net Ship * ❑Import to U.S. . ❑Export iron U.S. Port of entrylWI: Transporter signature(tor exports only): Data teavkrg U.S.: rr 17.TiransporterAcknowledgment of Recslint of Materials trampoter 1 Pn dffyped Name Signature fvtorr0t Day Year mature r Month Ray Year 18.Discrepancy 18a.Discrepancy Indication Space ❑quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Re)ec8ort Manifest Reference Number, i lob.Alternate Fadly(or Generator) U.S.EPA ID Number j. v u� Fa0NLS Phone: loc.Signature of PJlemale Facility(or Generator) nth ay Year CC 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1, 2. 3, 4. I 20.Designated Facility Owner or Operator:Cer08catbn of receipt of hazardous materials covered by the manifest except as noted in Item 18a rinte me gnakrre Mor'- Day ear 1 h2ft EPA Form 8700.22(frev.3.0) Previous editions are obsolete, DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)