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lqw X02057 Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) SC. 01 433. 1845 1175566 Forth Approved. OMB No. 2050-0039 DESIGNATED FACILITY TO U PTINATION STATE (IF REQUIRED) 772.0026 UNIFORM HAZARDAUS WASTE MANIFEST 1. Generator ID Number 1677322. 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number see 424_9 0 0 7750233 JJ 5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) Feder Freight: YBDEB YREIGHT (STI) 4521 SOOTS HIGHNAT 99 FRONTAGE ROAD 4526 SOUTH HIGHNAT 99 FRONTAGE ROAD Generato==l CA 95215 (219)466-2127- STOaTO1 CA 95215 (2191166-2127- 6. Transporter 1 Company Name U.S. EPA ID Number 21St CEMW ENIVIROMMM HANAGENERT OF NEVADA, LIG CAR.000164012 7.Fiter 2 Comi ame U. E A N er Q :U u • ► N�r� 1 y 8. Designated Facility Name and Site Address U.S. EPA ID Number GENERAL ENVIRONMENTAL NGT, LLC DHA PSC INVII OXINTAL SER®ICES 11855 OHITE ROCt.ROAD i. Facili sPhone: RAMCD11BUIrAt CA -95742 (916) 351-1981'. -• CAD98WS4183 ga HM 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group (d any)) 10. Containers 11. Total Quantity 12. Unit Wt.Nol. 13. Waste Codes No. Type a ?( 1. 11111263 VASTE PAINT RELATED MATERIAL 3 PGII RQ(D811) c� ®/ tom- 00.0 P 0111 0135 331 LU2. 0 NON-RCRA HAZARDOUS WTE LIQUID (LAIRS PAINT) coo I 0012 P. 291 3. AON-RCRA HASARDOUS OASTS LIQUID. (ORANGE_G1A)_.__-- - ®0� _. DN- 00 5 P 4, 14. Special Handling Instructions and Additional Information 0 I 10 Z Ti X f. 0 ) 2 k to, ('1) F U-12 - IRG(128) PRO# 1355769892•(2) F BLIQ-/1•- PRO#•1968755773 (3) FBF CWMLIQ-16 - PRO# 1446925831 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcimoWedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (di am a small quantity generator) is true. GeneratorstOfferors Pdntedfryped Name q /� Si natu month Day Year r aC� Z 6 6 J I� ? 16. International Ship ants ❑ Import to U.S. ❑Export from U.S. Port of entry/exit Transporter signature (for exports onty): Date leaving U.S.: W 17. Transporter AdnWedgment of Receipt of Materials 12 CO) Transporter 1 Printed/Typed Name Signature Month Day Year AJ 0�- i S f0 Z Tran 2 Printed/Typed Name natu Month Day Year e . lel 117 �/ G'f�✓ p> Jt1 18. Discrepancy Ise. Discrepancy Indication Space ❑ Quantity, ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. U .i 18b. Alternate Facility (or Generator) U.S. EPA ID Number Facilitys Phone: w a Z 18c. Signature of Alternate Facility (or Generator) Month Day Year H19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) G 1. H141 2. 3. -� � Hi•H- �^ I 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in (torn 18a Printed/T Name Signature Month Day Year b DESIGNATED FACILITY TO U PTINATION STATE (IF REQUIRED) 772.0026