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Please print❑rtype- <br /> UNIFpRM FIAZIIRDOUS 1 GeneratorlD Number Form Approved.OMB No.2Q51J 6039 <br /> t n,"82'�97F,. 2.Paga.1 of 3.Emacq Res nose Phone 4.Mantfest Trackl/n�Ndn16er <br /> WASTE MANl�E5T �,�i�' •'R..:- �®�1.J`g�� 1 � 5 <br /> 5.GeneralOrs!Name and Mailing Address <br /> i;�ar:s Shop 1 0 Cw f Generato's S is Address(iF different than mailing address} <br /> rhY4hn Rd <br /> Yep-.. ?c. r CA ='5377-912 <br /> Generators Phone: • . 'ft77 3 <br /> 6.lr a! 1 <br /> 77k Pi U.S.EPA ID Number <br /> 7.Transporter 2 Company Name " <br /> U.S-EPA fD Numher <br /> 8,Designated Facility Name and Site Address V HERMU FLUIDS TW U-5.EPA ID Numher <br /> "2533 SE CARPENTER DF• <br /> OR 970i5-8r:rj1 <br /> Facili y& 46115 Phoria: _ <br /> 9a. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number. <br /> HM and Packing Group(if any)) 10.Containers 11.Tataf 12-Unit <br /> Na• Type Quantity Wt•Noi. 13.Waste Codes <br /> HA MIRT}OUS WASTE SOL I <br /> 1'DPA1WD/+.JNbpnINFj) uSED 61 <br /> t- FiLTERSi <br /> W - -- - <br /> a 2- <br /> ru <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information ' <br /> TSa s TPE) 79'74e7,s 10 14?9 (A <br /> retained !� <br /> T "'Ar., Ortt�r to add srr yl>I,Stjt:�t ,.Y generator- conf err, agency ar1��5Csr 7 <br /> f:.. _ t(r} fir <br /> 15. GENERATO ISfOFFEROR'S CERTIFICATION; I hereby declare that the contents of IN.,consignment are fully and accurstaly described above b the proper shClassified, •- g f <br /> marked and labelediplacarded,and are"'all respects in proper Condition foe transport according to appficaNe international and national governmental regulations.IIfpexp name,area are packaged, <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. P�1 shipment and am Iha primary <br /> I canify that the waste mmirnVation statement identified in 40 CFR 262.27{a}(if I am a large quantity generator)or(o){if I am a small quantity generator}is true, <br /> GeneraW,V0ffemr's Printed(Typed Name <br /> Signahrre Month Day Year <br /> —116.IniematiOnal Shipments <br /> ❑Import to U.S. <br /> M Transporter signat ❑Export from U.5. Part of entrylexit: <br /> ure{for exports only]• _ <br /> IT 7ransporterAckrmwiedgmem of Reteipt of Materials Data leaving U.5 <br /> Transporter t Printecl(Typed Name <br /> Q Signature <br /> a Month Day Year <br /> zC TrAnsporter 2 Pdntedfl' Name e <br /> F SS�e MOnth Day Year <br /> 18.Discrepancy <br /> 18s.Discrepancy Indication Space <br /> Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑FW!Rejection <br /> 186.Alternate FadGty{or Generator} Ma test Reference Number: <br /> U.S.EPA ID Number <br /> Ca <br /> I Facility's Phone: <br /> L 180.Signature of A'lemale Facility{or Generator] <br /> Month Day Year <br /> 51 C7 19.Hazardous Waste Report Management Method Codes(is.,codes for hazardous waste treatment,disposal,and recycling systems} <br /> of t <br /> 0 2- 3. <br /> 4. <br /> 20•Designated Faclllty Owner or Operator:Cartification of receipt of hazardous ma[erials covered by the manifest except as noted in Item iiia <br /> PdrnedlTyped Name <br /> Signature Month Day Year <br /> EPR Form 17l]0.22(Rev.12-37) Previous editions are ohsolete, <br /> GENERATOR'S INITIAL COPY <br />