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Please print or type.(Form designed for use on elite(1 2-pitch)typewriter) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2 Page, of 3.Emergency Response PhoneC Manifest Tracking Number WASTE MANIFEST 1 6 1 01� 4 ff�L�Zpp''Jy -1 5.Generator's Name and Mailing Address 1 F L E Generator's Site Address(if different than mailing address) PC,Edi1029 400 4`'.1*illca Poxi T 95378 TilCA 9537F: Generator's Phone '110 ''? 9107 ATTN-[4bbie UT£it_a[' 6.Transporter 1 Company Name U.S.EPA ID Number - irrworal Services lin ,, A Ly V ; 9 3 d A� 6 u 7.Transporter 2 Company Name U.S.EPA ID Number ttfts ;—c{\fC il 1V 3F+ aero l• ::C ,_ !� G"moi S�. U.S.EPA ID Number !SW.W-41hA Road 6i � o � 4ii Grantwill ,UT,84029 Facility's Phone' f P,'i }' ga 9b.U.S.DCT Description(including Proper Shipping Name,Hazard Class,ID Number, 1D.Containers 11.Total 12.Unit al and Packing Group(if a 13.Waste Codes No. Type Quantity Wt.Nol. O CaY A LU Z w 0 3 4. 14 Special Handling Instructions and Additional Information 5 16. GENERATOR'SlOFFEROR'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, 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generators/ eror's Printed/Typed Name ignature Month Day Year 16.Interriaticnai Shipments Z ❑import to U.S. ❑Export from U.S. Port of entrylexii: Transporter signature(for exports ori ): Date leaving U.S.: w 17 Transporter Acknowledgment of Receipt of Materials a Transporter 1 PrintedlTyped Name Signature and a5 ear O EL Q Transporter 2 PrintedlTyped Name Sivaluze � 4 Month Day Year f1 � 18.Discrepancy 1 Sa.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑FuIV Rejection Manifest Reference Number 18b.Alternate Facility(or Generator) U.S.EPA ID Number a C) d LL Facility's Phone: I 18c.Signature of Alternate Facility(or Generator) Month pay Year a Z O 10 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) t. 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 Printed+Typed Name Signalure Month Dar Year EPA Forrn 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR .i&Z; Hall hAF to a Il it-A and,40 a,:,-eot Ote ste yv,io5rdk tt im �Fiit>�tiFap.