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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No:2050-0039 <br /> 1.Generator ID Number - 2 Page t of. 3 E cY n P o 4 Manifest Tracking Numban <br /> UNIFORM HAZARDOUS GAD48@98.717 7—� 4910.7':J� •+v x y r'� (��/ <br /> J <br /> WASTE MANIFEST ltt6�32 5, 74 SKS <br /> , 5 Generators Name and Mailing Addresso �nylIng address) <br /> VE <br /> j. Naslone Rd UU <br /> Generators Phone. r•.Q,19-931-1277 - EJEC '(r 7 <br /> 6 Transpmter I Compaa m , - - U.S,EPAID Number �.,E <br /> ;.t_t �aVSTEMs, `INC. TXROOW180: <br /> 7 Transpoder 2 Company NameHEq�,TH•OEPgIiTME T. <br /> .S.EVA ID Number <br /> B.Designated Facility Name and Site Address CLEAN HARBORS GRASSY-MOUNTAIN, "L1..C. � U.S,EPA Number i - <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41� flFF I�90 ' <br /> K�Da 3ES-8976 <br /> ARAGONITE , 'UT 94029 WTD491301748 <br /> Facility's Phone: <br /> ga 9b:U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Nuinbe6 10,Containers 11 Total 12.Unit 13.Waste Cgdes' - <br /> HIM .and Packing Group(IfahY)) - No. Type. Quantity'l: WW91. r <br /> 1 Nf7NE, NON RCRA HAZARDOUS WASTE 5Cn_ia;5. �j1t G 241 <br /> of '.DRY PAINT WASTE IN BASS'), NIA � cr �r�© <br /> z. <br /> w <br /> 3, - <br /> 4 <br /> 14 Special Handling Instructions and Additional lnfgmiaion �a( ,)s-j 17483, 151369645&- "VOR r7 <br /> 506,1151q-77 <br /> 'ROENGY #1-800h469-1766 (SAFETY ; <br /> `rt <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION:?I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shippingniand are dassli packaged <br /> marked and labeled/placarded,and are is all respects in proper condition for transport according to applicable international and national governmental regulations If export shipment and 1.am the Primary <br /> Exporter,I codify that the contents of this consignment contain to the tens of the attached.EPA Acknowledgment of Consent ramify minimization statement identified in 40 CFR 262.27(a)(if I am a Targe Ruantitygenerator)or,(b).(ifl am a small quantitygenerator)istrue. <br /> I cert; That the waste i <br /> Generators/Offerors PphtedFryped Name Signature .,� ° '" Month: Day Year <br /> 16 IntdmahonaPShipments <br /> i- — ❑fmpgrt to U.S. ❑Export from D.S. of dniryl9xiti <br /> z: Transporter signature(for exports only) ra Date leaving0.S.: <br /> of <br /> w: 17 Transporter Acknowledgment of Receipt of Materials <br /> Trans ri PdntpedRYped a4. Signature. : Month Day <br /> Year <br /> Z Transporter 2 Pnnted/ryp me �•' ignatu Month Day Year <br /> 14,Discrepancy <br /> 1fla Discrepancy Indication Space ❑ Quantity 1-1 Type ❑Residue ❑Partial Relectlon ❑Full Resection <br /> . . .. <br /> .Manifest Reference Number: <br /> 18b Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> µ Faalnys Phone; <br /> do led 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 /> 20 Designated Factldy Owner or Operator,,Certification of receipt of hazardous materials covered by the manifest jxcept'ffihdh in Item"18a - x'f i �[ <br /> Prins, gyped Name ' Signature qr '�Motdh• • ay Yeer- <br /> y h <br /> a. <br /> •EPA Form 8700-22(Rev.3-05) Previous edition ane obsolete. "` 1� ` "'" �t `'`+ ,IONATED FACILITY TO GENERATOR, <br />