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D'TS C.. 0:0779-. 0.42.3 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone OF4Mt Vt <br /> WASTE MANIFEST Ns • " <br /> M 7 O JJ K� � t <br /> 5.Generators Name and Mading Address Generator's Site Address(d different than mailing address) <br /> tcPt(A tEST lirkc. IrA(-, wt-ST lNC. <br /> 'kO-46 SCAPOR-T j,04 D OIL <br /> `^1• SAcN-RwJC-47-0 C;-A- AS(oq� L-A-T-V R-oP cA. X5"330 <br /> Generators Phone: r1 no <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> N CJ t 1-014 rh L 5 C- - k-3 C. CAR C000 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> t\(-GV-Cif -eN 0\.L k <br /> -v 1;7- <br /> C- <br /> F: <br /> 1v�w Alk C- 0 <br /> Faciiiii es Phone: <br /> i <br /> Ba 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(f any)) No. Type Quantity WtNol. <br /> �G-R-A 1;FA�A1W OvS�`' A 57;0 Lk QV 1p 2.2(Q L.v w�rrt IL) e\ TT (00ly 4 <br /> i 2. <br /> c3 <br /> i <br /> 3. <br /> ZZ <br /> 4. <br /> '14.Sperm Handling Instr cis and Additional Information <br /> ;-vt�5t= p�OPCr{� P�SortAt. p,to7-c cr��� CQ�IPw�g,vT- <br /> fso4�00 3g2-aro <br /> INC-- V 057 o1 roc' q(45;01 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consi n ment 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 govemmenta ns.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this cons ig ment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization stateme ntified in 40 CFR 262.21(a)(l I am a large quantity generator)or(b) a small q ne s <br /> 1 Generators/ Printed/Typed N t Month Ye <br /> -j 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transpo �1 PrinledlTypedName Signature Month Day Y <br /> O G <br /> p� <br /> TrIiiiiisF&W 2 IRMIllildryped Nom Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> R <br /> • v <br /> LL Facility's Prone: <br /> W 16c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ 1. 2. 3. 4. ' <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the pniLftt except as noted in hem 18a <br /> Prim Name nater Month Day Year <br /> J SD Nay moo,.. 7J �'�� d 2� o <br /> EPA Farm 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 10434.2217 <br />