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0 <br /> 51-7--it70 ESS 869562 55746 <br /> Please print ort e.(Form designed for use on elite(12-pitchtypewriter. Form Approved.DMB No.2050 0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3,Emergency Response Phone a est/r�askm umber �p <br /> WASTE MANIFEST g 7 77- 6 O 0`t 9 . 0663 JJ <br /> 5.Generator's Name and MaSng Address fo Generator s Sika Address(f different ihan mailing address) <br /> HORN DEPOT C/O 3E COMPANY HONE DEPOT 00,,1006 <br /> 1909 ASTON AVENUE 1100 250 COMMERCE AVE <br /> Ganarstii h&UD CA 92006 f aw 451-834 - <br /> 6.Transporter 1 Ccmpeny Name U.S.EPA ID Number <br /> 21St CERMY EHI <br /> 7.Transporter 2 Company Name U.S.EPA ID Number i <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> BURLINGTON ENVIRONMENTAL, LLC. KENT FACILITY <br /> 20245 77TH AVENUE SOUTH <br /> Facility's Phone: KENT, VA 98032 (253) 872-8030 WM991281767 <br /> ga, 9b.U.S.DOT Descripffan(including Proper Shipping Name,Hazard Class,ID Number, 10.Cents ars 11.Tomei 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1 UN1950 WASTE AEROSOLS, FLAMMABLE, N,031 (METHYL ETHYL KETONE) B` 0001 0035 331 <br /> 0 RC 2.1 DOT-SP12842 QQ(D001=100)` <br /> W TIE <br /> UA <br /> a, UN1263 WASTE PAINT RELATED MATERIAL 3 PGII RQ(0001-100) D001 D035 331 <br /> 3. .If Tq - , - 1 PGII ,(r <br /> X �T <br /> a, ffi (411 <br /> ` r r : <br /> Y w, _ ) <br /> 14.Spsdal tiandi ng Instruct ons and Addit onal f donnatbn t / G1" <br /> (1) HONB2.1-03 - ERG(126) AEROSOLS (2) HOME3-03'- ERG(128) FLAKIIIABLE LOOSEPACK <br /> LPROPOBAL$E. <br /> 16. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately ascribed above by the proper shipping name,and are classified,packaged, <br /> marked and fabeledlptecarded,and are In all respects In proper condition for transport according to applicable International and national governmental regulations.N export shipment and I am the Primary <br /> _...._...___.—6xpoder,.I cargty.U+at the.contents-of.This.cooslgomant�onform.to.titelegnsAfthaaltadiSd.EPANCKuS2sYlYleSfHtnalltgL�gilSgiit<....,_: � <br /> I certify that the waste m[Mmizatlon statement ide allied In QO CFR 262.27(a)Of i am a large quantity generator)or(b)of I am a small quantity generator)is true. <br /> Generalor'slOffaror's Printed/Typed(dame Sig m ur —_ Month Day Year <br /> i 16.Iniernatlonai Shipments f <br /> ®import io U.S. Q Export from U.S, Port of enlrylexlf: <br /> Transporter slg:rature(for exports only): Date leaving U.S.: <br /> Ve 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter—7010d/Typed Name Signature. Mbnth Day Year <br /> N Al f.• 14 Ah- o� 4 � <br /> rens er 2 Printed/rypedI A <br /> ,. <br /> � f,,"�, -`'"�: •.,. ^r... ,,. r .,..:e.a,.aZt �s:., ,`: a�a.�:x.;.w 1..`. .x.+✓.>_m .r.:� <br /> Monty Day Year <br /> 18.Discrepancy 1 <br /> 18a,tkscrepancy indication Space Quantity 0 Type ❑Residue ❑Part!a!Rejection Q Full Rejection <br /> i <br /> Manifest Reference Number: <br /> 16b.Akernate Facility(or Generator) U.S EPA ID Number <br /> V <br /> uQr. Facility's Phone. <br /> 18c.Signature of Alternate Fad ily orGenerator) on) Day Year <br /> I <br /> 19.Hazardous Waste Report Management Whad Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1, 2. 3, k. <br /> i <br /> 24.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by t"a est except as noted in Item IBe <br /> Pr! Month ay ser <br /> EPA Form 87 •22(Rev.3-D5) Previous editions Ere obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IIF REQUIRED) <br />