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:ase print or type. (I-orm aesignea Tor use on else (iz-pitcn) typewriter.) UNIFORM HAZARDOUS 1. Generator ID Number WASTE MANIFEST 5. Generators Name and Mailing Address Generators Phone: - 6. Transporter 1 Company Name 7. Transporter 2 Company Name rorm Approved. UMb No. 2UbU-UU39 3. Emergency Response Phone 4. Manifest Tracking Number VZSKS Generators Site Address (if different than mailing address) F�❑D IPERMIT/SERVICES 8. Designated Facility Name and Site Address U.S. EPA ID Number US ECOLOGY NEVAN 1 ! M1. L.ES S 11F BEA TT RPM 343001" Facility's Phone: Nt1`" .' ;t?3! j 117"t °t ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) No. Type Quantity Wt.Nol. 13. Waste Codes 1. NDN Rf"RP HVIZ AR73IJUS WF6 f l;' 1.. 4ONA. US NON LU 1 (f)JIN SLUDGE AND WATFRl z 2. W 15. GENERATOR'SIOFFEROR'SCERTIFICATION: I hereby declare that the corifents of this cohsignmentare fully and acduretely described above by the proper shipping name, and are dassified, 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 EPAAcknowledgment 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) (if I am a small quantity generator) is true. Generators/Offerors Printedrryped Name Signature Month Day Year -i 16. International Shipments H ❑ Import to U.S. Export from U.S. Port of entry/exit: lexit: ❑ rY Z Transporter signature (for exports only): Date leaving U.S.: Ll 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O a U) Transporter 2 Printed/Typed Name Signature Month Day Year a 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number U tai Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Q Month Day Year Z n19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedrTyped Name Signature Month Day Year -PA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY