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997507 105181 <br /> Plag$eIftorjj�, Fenn d nod for use on elite 12 itch)typewrlter. "' Fomt proved,OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phona eat ac ng mer <br /> WASTE MANIFEST , _ 0056 55 51. JJ K <br /> 5.Generator's leme and M01VAddr Garrarabfa Address(k different Ulan rte!tng address) <br /> Arf <br /> Rose Depot C/O PSC Atta. Hoge Depot CSR HORS DEPOT #801896 <br /> 5151 San Felipe HONE DEPOT #801996 259 COURIC6 AVE <br /> Gerer56 ANZICA CA 153H 1219)275- <br /> 8.Transporter S Company Name U.S.EPA 10 Number <br /> 21st CENMY ED+MOWNTAL bINPGEM PT OF Niamm LLC CAR00012 <br /> 7, Name U.S. <br /> 8 <br /> 011fgnated FadwyName and Ske Address U.S.EPA 10 Number i <br /> BURLINGTON E M104NENTAL, LLC, XENT FACILITY <br /> 2920 71TH AVENUE SOM 1 <br /> FacW6Phon0WT, WA 98932 253 872-8030 WAD991281767• <br /> g, 9b.U.S.DOT DaWp#on(krdudtng Proper 8hIppIng Name,hazard Class,ID Number, 10•Contdrwrs 111TOW 12,Unk 13,Wesly Codes <br /> HM andPeo"Group(lard No. Type Ouentky Wtivoi, <br /> ( od 1 UN1959 WASTE AEROSOLS, PLANTABLE 2.1 00T 9F 11296 W11187=11) ®d I 4Q 3q P 991 D#05 0007 <br /> DF <br /> �I UN1993 WASTE FLUME LIQUIDS, N.O.S. (ACETONE, NETHYL MTM091 0935 331 <br /> ftQ IMNE) 3 POII (FLASHPOIRTa20.114) RQ(D901=199) 4 a4 © P <br /> R 3.02811 WASTK TOIIC, LIQUIDS, ORGANIC, R.O.S. (2,4-0) 6.1 PGII 0 0 d07 #96 0016 331- <br /> -TOXIC' RQ(0116.10) ����� DF + P <br /> 4'UP3266 WASTE CORROSIVE LIQUID, BASIC, INORGANIC, N.O.S. 30111 a, II102 122 <br /> X HYDROXIDE, POTASSIUR HYDROXIDE) 8 FGII RQ(08! =I 0® f 178< d0 2 P <br /> 14. Hindift kistnrd andAMIF.W hrforma <br /> (1) ROT62.1-04 - 660(126) OSOLS-AC ATIO (2) Hmmi - ER0(128) nums Loma (3) 6.1L-#4 - noon) <br /> TOXIC (LIQUIDS ONLY).(#) EONSID-05 - 90(151) ALKALINE/CORROSIVE LFROPOBAL#:- - <br /> 15, GENERATM31OFFERORS CERTIFICATION:I hereby declare that the contents of tide consWo rent are fully and uately described above by the proper shipping name,and are classiked,padm*, <br /> madred and a ed,and=in all respells in proper cordklton for transport acomrkrg to a International and nakond governmental regulations.if export shipment and I am the Primary <br /> Exporter,i certify Dalt the ocaterk of M coaslgnmarrl conform to he temps of the attached EPAAdorowledgrnaM of Conse+t. <br /> I cGy that Bre wase mWffjzaft saterneat Identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)f f I am a srrredgM tffy geneator)k true, <br /> GenerajofjDllerofs PdnadfTypel Nome Month DayrA 1111 L02 Year <br /> 21 or <br /> f . <br /> Inlemi5nal shloiwiit-57- ❑Mnport U.3. LI ExPwt from . . ort of <br /> TranspoMar (fa a only): <br /> 1T.TrorrsporterAcknowtedgmaMCR®wlPlotlterlab <br /> Tw*orfer S lorntedflyp Name Sgnatiae Manth Day Vior <br /> s'N U o- <br /> raneportar2 yped ,. Sipnatrae vMonth Day Year <br /> 18.9wepancy 1 1--I <br /> tea.f>tecreymncy Indbadorr Space O ntsy []Type tJ ResWue Q Pectic R.1ec1lon ❑Fuk Rejection <br /> Manifest Refarance Number. <br /> 18b.Nlemeie Fa ty(or Ganntor) U.S.EPA ID Number <br /> to <br /> u FacltRt+s Fhorre: <br /> 1fk. lure ofmarnate Fwft or GeneratorMon y Year <br /> H19,Hazardous Warta Report Maregement Method Codes(te.,codes for hazardous waste treatment disposal,and regdig systems) <br /> C 1 2. 3. 4. <br /> H141 H#61 Hi41 Hll1 IHIH <br /> 20:0aslgnalectFaakty 0vareror .Operator:Certification of receiptofhazardous materWscovered by the mankesl exceptx now <br /> g aw t. Main.... y <br /> Print yped Name 4 <br /> . P <br /> EFA Form 870a22(Rev.M5)P vtoused'ntlonsareobsolete. DESIf3NATE F CILITYTO DESTINATION STATE(IF REQUIRED);;.: <br /> t <br />