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P ale print or tppet: {Form designed farLcs on alit8 12 ° , <br />pRch typiter) ff �r Form A <br />w, UNIFOR�1 HAZARDDUS 1 Gene.alor ID Number 2.P 1 of 3. pproved°. OMB No. 2060.0039 <br />gen Response Phone 4. Mann/ff��ast Tracking N(urnb*r /� <br />�f1ASTE fifllNIFEST LltI3:�7A�i 4 i t377) 'a7?. ai9 QV a7 LJ!'►� <br />5 Generators Name and May9ngAtldrass Generators Site Addis -571f �fferert than mailing address} <br />�4TY CiiIMCt! OF.;Sf#'V� i I1GY #fi lliiY " CIIY AND CMTY OF sm i1AGY tk l€Y <br />13" AMT Stan; S E tt� r I.zs <br />GeneratcesPhone: S F SCO Calaft , (415}n1 -311l INCY Co "371 <br />D. Transporter 1 Company Name <br />SIEPICYCEE SPECIALTY WST£ 601_UTIONS INC US.E AiE3Mumbar <br />7; Transporter2 Company Names MIC1QiI(i4 <br />U.S. EPA ID Number <br />e.Dosignated FaciftyNameandSikrAddress <br />HST ilex EMY#R01DrAffiL I:* pl*-M, <br />LL6 ".17 5. EPA ID Numtxrx ` <br />t14S kkabb Arlwe &Sf <br />Fadl sPhara;T*M NY 3141 1115) 515-241 <br />WNW1395338 <br />f3 <br />ga , gb: U.S. DOT Description (preluding PmWShiRping Name, Hazard Ciasa, )D NrmW. itf_ Containers MM and! Packing Group (i( any)) - 11. To181• 12. Unit <br />Nkz Type omnlHy c 13. Waste Codes <br />f dill!!► TE FL L <br />o E �lif l D F F{ 1� <br />. ri! � � .r.-}: s1 z s''� ' -• � _ � �. vii+► � i� f' y ',,° :� 1. <br />SY <br />I.A. <br />4, -7 +'fA?d0a us w.�t s-r� drat i f�.r1.S <br />t4. Handling'IneiruMnsandAdditiomllnformaticn <br />tit llc�lir�-wt ,- t�ibi�.5�i NrJllti�Flf£15€1€CIC �1 f�� ��'�12�-�0 - - <br />trli#5S t� 1 #775► :oa �.t ,r,:+ 4caoRY <br />u OENERArOUX-TZWR'S.CERTIFICATIQN' hembLydeciareWthemntenisuithis=mgrxnerrcaralully-andactu tydescibed-aboveb trio <br />marked and laheledlplacarded, and are in all respects r`n proper Cnrrdttion fort acmro n � Y Ampa<ah �m9 �me-�� �e da�i6eQ.pacl gg� i <br />res s 9 applicable hternaiionaland national govemmantal regulatikms. if axpert shipment and I am the Prmary <br />Exporter. I"certtfythat the contents of this consignment conform to Via Larms of the waked EPAAcknowledgmenl of Consent p <br />I cw* that the waste mhmlzaticn statement identAN In 40'GFR 26227(a) (if I am a Large Quantily generator) or (b) if I am a small, quantity <br />Gengarlor roes Printeci f d Names 9 by generator) IS True; <br />. � k Signature /' Month Qay Peer . . <br />[.0 o t <br />16, In nal Shipments , <br />PmpoR hx U.S. Export from U.S. Port Of entryletdf: <br />Tl�sporter signature (for exports only): Qais laevlrrg U,S,: <br />17. TraneporlsrAcit V*L-dgment of Receipt hf Ma�tials, . <br />Tnanspprrsr 1 yped Nance Sipna�re <br />�'�,F4 a OI Mkuvfr Icy Year <br />ITR nspeyr�tsr2Pifn yped f :SL -*'.V <br />a►;;kr1 Month Day .Year <br />i~*�.%' .. <br />, <br />,> to ��,�,� ,� � .� ,,• � <br />18tr.AibetrtateFac�Giv4or enerat{I.C1 L' �r '.�a <br />-., <br />. far. and <br />FacilitysPhona - this giener for IS snipping.` <br />16C. Signature ofMemale Fadlity (or Generator) <br />Month Day, year <br />y. <br />19. Hazardous sts Report ManegerrwtMethod Codes (I.e., codas for hazardous waste treatment, d serosal, and _ cin <br />Lao1, �y 9systems) <br />20. Des noted Fad it CMmer or <br />9 y CQeraior. CeRifreation of receipt of hazardous materials eCv�ad bye manifest except as nailed in Ipem r8a ``� <br />Print yp m <br />y S U <br />o <br />)nr ay <br />EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. <br />CIE51 MATEp FACILITY TO GENERATOR <br />JAN 5 20 ,11 <br />