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PSL 1--p i® SK SHIP# 23 J668M <br /> Please print or type. +- S;' Form Approved.OMB No.2050-0039 <br /> UNIRIwi-~HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Em aes e P 4.Manifest Tracking Number <br /> c�Re�coa ��ar� 11 �f°1?�m y; -- �, $K$ <br /> WASTE MANIFEST T1 . <br /> 5.Ggerators Name and Mailing Pddress ai Generators Site Address(if different than mailing address) <br /> Ascalon t-,t.,cQier Brands Inc. <br /> 1905 IMcheary Ave <br /> ESCAL CA '95320-113000 <br /> Generators Phone; �9- ��-5�1 t <br /> 6.TIM IiW-IITLENE�r4 SYSTEMS INN U.S EPA ID Number <br /> 7.Transporter 2 Com an Nartre. U.S.EPA ID Number <br /> LE.t�j fl�1NORS EWV SVC INC. MAD0393�. 251 <br /> 8,Designated Facility Name and Site Address CLEAN h r�?P O RS DEER TRAIL LUU.S.EPA ID Number <br /> IU555 E HIGHWAY 36 <br /> DEER TRAIL a CU U105 <br /> 970-386-2293 CIDD991300484 <br /> Facilitys Phone: . <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wtivol. <br /> FAZARDOUS WASTE, LIQUID} I a�`'� Doll i��5 <br /> o :SILVER), 9, P3 III <br /> W <br /> C7 <br /> 3. <br /> 4. <br /> j 14.Special Handling Instructions and Additional Information T Sir)y�y 84573`'=�e FS 1 14 SCS <br /> 1)ERS*171 r <br /> 24H EI:_HCl:NGY dO-4fiLi-176�b-CH/SK/TFI-Can ract retained by gefrrrator confers agency autbori ' <br /> ,, <br /> 24H.E...:-,._ rl transom-ter to add or slbbstit+ute additional tr' E._ :n�,rters or, -OV-1 -"43ehalf, <br /> t5. 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, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the alladred EPAAdutovAedgment of Consent <br /> I cerffy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)lift am a small quantity generator)is true. <br /> GeneratorslOfferoes Printed/Typed Name (// Signature Month Day Year <br /> QA <br /> 16.International Shipments from U.S. <br /> Port of en lexit <br /> I. 0 Import to U.S. ❑� by <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> F Transporter 1 1Printedffyped Jame Signahxe Month Day Year <br /> a <br /> Z Trans po 2 Printed/Typed Name hue r Month Day Year <br /> 19.Apiscrepancy'. n <br /> iia:Discrepancy Indication Space Qaantlty,, Type.' Q � j °`' ❑Partial Rejection ❑Futl Relecfion <br /> Manifest Reference Number, <br /> 181b.NtemaiiwFact ity(or Generator) U.S.EPA ID Number <br /> J_ <br /> V � <br /> L <br /> t. Fadfrt¢s Phone: . <br /> w 18c,Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes fpr hazardous waste treatment,disposal,and recycling systems) <br /> 1 2. 3. 4. <br /> I l �- <br /> 20,Designated Facility Owner or Operator.Certification of receipt of hazardous materials Covered by the manifest except as noteddn Item 18a <br /> PrintedlTyped Name - Yw <br /> y-�� Signature rn / �J'}/� Tth Y <br /> Efn <br /> f EPi VWTDI� '1 1&2A�is Xious editions are obsolete. DESIGNATkD FACILITY TO GENERATOR <br /> I � <br />