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Please print or type. (Form designed for use no erre M 9 ,it ,l e -n -, -c6 a/B Irl <br />_--_._.__,._,..•.,.xP.,..::w,.r ,,,. y -,.t <br />Fon Approved. OMB No. 2050.0039 <br />UNIFORM HAZARDOUS 1. Generator lD NumberG>tJ,.O0/Tp (p5L 2. Pagelof 3.Emergerrcy Response Phone 0.ManirwtTrackln Number <br />WASTE MANIFEST 'I I <br />OI SfQ '1OI ,, 0001�L2838 JJK <br />5. Generaws Name <br />and Mailing— <br />UJP I«�J Generstoes SMF rays(i!ddlerent NannumingadNess) <br />K. <br />{ 09010 KOtZ WJr 'S <br />COMv.}wx]r"(Q�n."J <br />C%Je-V&ap FAQ K. IL-5 %�l.ff S B.TDeJ .�1s205 <br />Ganerebrs Phone: Cl'3- Z Z`i - S Z <br />6. Tmnspwter 1 Company Name <br />U.S. EPA ID Number <br />M©c U �u�a�►s — A� S�r,lc�s ��sc ca jjqze <br />7. Twrxspoder <br />2 Company Name <br />// }}�` U.S. EPA ID Numher <br />I\ {Faf`' tY1�Y U 4 1i � I C5, <br />Val <br />8. Designated dk'y Name and Ske Address ,`7}U.S. EPA ID Number <br />k0fo HCl "ft I7r7.4 5i <br />Lt)�� &-^(i CA 4101{3 <br />Fad, sPhone: Oii �'J?' Z C)%) TJ y(59D (01 <br />U.S. DOT=: <br />OT Description (inducing Pmpar Shipping Name, Hazard Class, ID Number, 10. Containers <br />HM antl Paddrg Group (tt any)) 11. Total 72. Unit <br />No. Type Quantity Wt N01. 13. Waste Codes <br />017tt' 0012. ::,, l., �i )z 0, -S 1 <br />�Z. <br />sE2. <br />TE <br />ISPOSAL. TREA ASO cons RECENm, <br />E CR Say DAM Pol <br />� r r%fYOTECT1pN O T OF Ixf N SINE <br />NM71 UtONMF).rT,LL <br />:1I IN ThE ENVIRONFACR,IrY <br />V AN <br />CY w CVN'ry0L- <br />4. f]lAQrS TO STATE REGU,ADONS. CROS Y ACT OF 1 6 T Ko_Y NS OF <br />'(CbreD NGLyC1F➢T TIfE Rl1-tRF�N(gL WA ANDALLlS <br />�wAALL NE a ' <br />STE NAY S' •' <br />14. Special Handling lnsWctions and A.dAfional inform iDn <br />16'/6stlivntt�a¢oy,Loc: <vlaTE¢•"/tkiEtiEgF•>T, �27�t <br />I <br />-" . t <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: hereby declare That the carlenls of glis consignment are fully and amseety described above by the pmpar SMP" name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respect in proper condition for aanspolt to <br />acmrdlrg applicable international and national governmental regulations. II export shipment and I am the Primary <br />Exporter, I certify mat the content W INS wnslgnmenlconfonn to ft ternw of vire stradxsd EPAAdmWedgm int of Consent. <br />.. I certify that erb waste on nimfiationsfntement identified in 40 CFR 26Z27(a) (al am a large quantry gepWQbW or (b) (d am a small quantity generator) is true. <br />_ <br />Generator rs Prnte4gyped Name S raWre Month <br />r <� Da Y Year <br />J 16. Inlematiorel SNpment A J Li J`7 <br />❑ Impod to U.S. ❑ Export from U.S. Port <br />of enWexit <br />Tramporter signature (for exports only): Date leaving U.S.: <br />W 17. TranspotowAcknwyedgmenl ofROD* of Materials <br />TranspoMrl mgiWTyped Name <br />OJ _ nna p Mont Day Year <br />'erg <br />ran Print yped Name <br />Q <br />f `r __ Month Day Year <br />6--'5 IL( <br />18. Discrepancy <br />tea. Discrepancy Indication Space ❑ Quantity El}e Type eb El <br />FullRefection <br />18b. Akemate Facility (or Generator) Manifest u <br />Z5 U.S. EPA ID Number <br />U <br />Facilitys Phone (_ 1`/'D <br />L.f YrY^ <br />ITIf- <br />W' 18c. Signature of MtemataFagtity (or Generator) • nr_pq pre ar-Ar. <br />Q - iiZh- Month Day Year <br />z <br />h19. <br />Hazardous Waste RepodManagemenl Method Codes (i.e., codes for hazardous waste beaanenl, disposal, and recycling systems) <br />2. <br />3. 4. <br />1 <br />20, Designated Facility Owner or Operator Certification of receipl of hazardous materials covered by the manpest except as ndepin Item 18a y' <br />Pdntedityped Na - Signature Month Day r <br />N <br />EPA <br />Form 8700-22 (Rev :LD51 PreMult editions are ob t <br />soe e. DESIGNATED FACILITY TO GENERATOR <br />