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Please print or type. ERATOR 1. I UNIFORM HAZARDOUS <br />WASTE MANIFEST N/A <br />1. Generator ID Number 2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />888-7E35-7225 <br />1-villi nplii uveu. Linn° NU. ZUDIJ-UV..1 <br />4. Manifest Tracking Number <br />014710204 FLE Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Mitsubishi Chemical Advanced Materials <br />3837 Imperial Way <br />Stockton, CA 95215 <br />Generator's Phone: 610-320-6610 I Transporter 1 Company Name U.S EPA ID Number <br />Advanced Chemical Transport Inc./DBA ACTermiro I CAR000070540 <br />Transporter 2 Company Name U.S. EPA ID Number EnVronmental Management Technologies <br />I CAR000183574 <br />Facility's <br />Designated <br />Emironmental <br />31915 <br />Parker <br />Facility Name and Site Address U.S. EPA ID Number <br />Waste Solutions <br />Industrial Ln. AZR000520478 <br />Sout.....,_h AZ 85344 <br />Phone: d(f-227-0189 I <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 Containers 11. Total 12. Unit HMand Packing Group Of any)) No Type Quantity Wt.Nol 13. Waste Codes <br />1Non-RCRA Hazardous Waste Solid (Oily Solids) <br />/ <br />ur.,.. <br />21C <br />P 352 <br /> j GEN 2. <br />3 <br />4 <br />14. Special Handling Instructions and Additional Information Project Number 288265 Document ft D350250 <br />1) EWS MIL- hc- S-S-13 C- <br />15 GENERATOR'S/OFFEROR'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 attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) Of I am a large quantity generator) or (b) (if] am a small quantity generator) is true. <br />Generators/Offerors Printed/Typed Name Month Day Year Signaturri.iresoced. <br />• eo ;...,..,._ `f I 3- 121 <br />1— <br />„?. <br />at. S i 16. Intern pments <br />Import to U.S Export from U.S. Port of entry,exit, <br />Transporter signature (for exports only). Date leaving U.S. <br />CC ILI <br />lti <br />0 a. cr, z <br />g i-- <br />17 Transporter Acknowledgment of Receipt of Matenals <br />Transpo 12Z/TrygName 6 Signature Month Day Year <br />/ / i'VC7 A. I ("1--- I Le I S— 1 ai Tr <br />fr" <br />per <br />it-I—tr)(1,,,/ <br />2 Printed/Typed Name <br />ta_ Li..._.1_2: <br />Signature Month Day Year <br />I --------r7,, 2—, - I 1-f- 1 ( 9—P-I ) FACILITY 18. Discrepancy / <br />Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U S. EPA ID Number <br />Facility's Phone: I DESIGNATE( Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1 2. 3 4. <br />20, Casignated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as n in Item 18a <br />Printed/Typed Name Signature tAonth Day Year <br />_jYl 4CP,eie14—, ,1,,Pe...4,0•"Yt—......' I VI it r2( <br />rm (Rev. - revious editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />