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1w76-1 "2= 463 2487833 <br /> OptPleaOpt or type•(Farm designed fwuse on elite(12-piieh)typewriter,) FotmRpproved,{}h?8 No.205O.O039 <br /> UNIFORM HAZARDOUS 1•GoaMWIDNarnber 2.Pa1 <br /> e101` 3.EmccGeruyResp0nsefhW 4.Manifest TtackingNumher <br /> WASTE MAHIFEST CALOD0391073 (877) 577-2669 OaDJt- U H SAT <br /> S.Geecrafors Name aad Ma&oAddrass Generalos sSiaAddmss(if different than—IN address) <br /> 116 LATS STORES 9I6 LOTS 14451 <br /> HE P1iILLIP 0 ATM: DERA FEPARU 2bai H. INCY MD. <br /> Geaeratoral�Itona: I;DLUIfEUS All 43228 (514)27$-279D Tl'.ACY CA 95375 [29R)B3R-6312 <br /> 6.Transporter 1 CarnpanyName E}.S.EPAIO Numtfer <br /> 21s Century Environmental flanaRt:Tltent Of California. LP CAR000210517 <br /> 7.Tram Cerapan Name US-WAIDNumber <br /> B.Desigst VFaarty Name and WeAdaess US.EPAIDNumber <br /> 21ST CENTURY ERVIROMEM1 t fl5E EW OF MYNA, LLC <br /> 205 RULPIKS DRIVE EAST <br /> Fa tysPt-w-,FERKLEY, PV 654118 (7753 575-2761( NVT39$i]g9533B <br /> ga. 9b.U.S.DOT Pesafpbm(mctud"ug PMper Wpp V Name.H=rd Class,ID Rmber. 1 a.Cpntaitfcrc. 14.Total 12.unit 1Nasfe Codes <br /> HM 13. <br /> andPaGrnup(Aany)) tSa. ;Yie Quantity Vltltrnt. <br /> 1' U91959 V95TE A.ERASt11.S 2_1 RIN61=120ti 331 D061 <br /> •� 2. te d, r x.-�y�r c r r - <br /> �r�"" .Yr 1Y1 i` ` c {y n 1p�, t.�,ar} [� e 331 <br /> t4` tpm <br /> FF 0985 <br /> ar{ n~ n` f r t two. <br /> r 14 j) Q F�rf9 Y✓1 <br /> 1 �- 3 Irl u c/ <br /> 4. #Z rntt— t• Ir r <br /> urn.. x,..• .. �....... a...� .. ... , [tr „� �Y4yt 2 <br /> mn,sw <br /> 14.Specht Handling Irtisbnrctions arXIAdQii'pnat Infotmalbn <br /> (1) ILP OSOLS-D2 - EIF&/h(11261 PEROMS t <br /> _�«-„ V�Kn w n n� r•� 7 '•t y nn i[, � ,:J �r ,�CJST�1�LS� � � 4x1 �� <br /> [i i 4 V n4^ic4 J y f <br /> i5 .G NSRATORSfllFhk[tORS T1PoCAt10N:ft'IcrchydedaretbatLhetvnEcntsoftln WeQme£lane Wand !<ff*d,pecks d, <br /> m34edardWb61edlpfaca04,andaseIna m*dsctl cotdj;Mfurbmporta=dcgtonatixdg•,tvemr=taltegAetions.E;c ar stiPmpllarrdiamfhaPtinzy <br /> Fxpater,l oesGiythatttlearlterlisoithiscoct5ignynallt crxrforsn tethe tnxtnsol the atfa�od EPAttc,+cnarvfedgmrnt�Corssertt <br /> 1 certify thatGle�astenv�im'nafionstatenrnxrt idctdrfied kr4DCFR?62.27(a)(d I am a Wrgequit}'9dwrd�)orfi)(rfi amasrnaG Quantity ge„araRrorjss We. <br /> sl0ffanrsPrin[odrt Narsle� Signatur rt Da Ye r <br /> ...r 1fi.b7leliiatipRal S �Pn.l;J1s� ��^^••--�� <br /> ❑I wtoi3S. 1JFxponttiamU Podolentsyo= <br /> - TtansporterslgnaWrc(for exports Doty); Date leaving U.S,, <br /> LU <br /> i T.TSaivt�Cdgment otRnxe o_f btateriats <br /> Franspart rinraTmo Name Sgnature Me Year <br /> co -7 1 A/i <br /> 0. <br /> Tra c Pdnre¢dfyped N fi Sign azure Month €lay Year <br /> 1a,t�crepancy <br /> 1Ba.Diwepancylrxri6aftis"ou ❑purity ElTM OResidua ❑Par&atRe)ecGori CIFu9R*dion <br /> ManifestReicrencCNurnber: . <br /> i8b.AlfernaieFaptty(arGeneratpr) it S:EPAIf3Nrm:bcr_ <br /> U <br /> LUu�- Facditys t>twrte; <br /> lttc signaiueofRrtemateFvuu?ly{or Generator} <br /> (tooth Day Year <br /> z <br /> 19.tta�ardousVyas(aReportlCSanagementNelhod Codes(F.e.,codes[ahataKdurs=,,e frcahtnot dspusat.andrecyclrgsystems) t <br /> 2D.Oes 4rtated Fat ty p��ner w 4lperatar Ceetifcation al rete pl a`Razatdous M- teriats comfed bythe rna Yni empt is Wed in iters 18a <br /> Arintedtryped Name Signature Monul tray Year <br /> -S /,E- I t. 109 2--) &, <br /> EPA Form 8700-22(Rev.3 -) PM40useditions are obsotete DESICNATEI)FACILITYro DESTtt3A`rm STATE(IF REQUIRED) <br /> SEP `TSG. <br />