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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 9 II II1 Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.Generator lD Number(�ftpppoq� 6 !� 2.Pagel of 3.Emergency Response Phone LMan' tTrackln Number <br /> WASTE MANIFEST `1 GE sly ak3-01 w 10001 638 JJK <br /> 5,Generator's Nam 1and cMailing rens 2 Generators site Address(8 different than mailing address) <br /> joq<zIo "1Zoc2 {�aTar �33 wo.K � <br /> ojevae o prati KS(oLZtI sxxLT-D0.3 r� °}SzoS <br /> Genermo(s Phone: co— Lvq^ tJ Z <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> M©k( Lu Eado2loo _ -hi CAT u ( 4243 <br /> 7.Transporter 2 Company Name p US,CtEPA ID Number <br /> 1V t t`' '1r\tiV "(CJ lt� I2t. -I C. l_4-1" l ( Yt� / ?�I <br /> B. ted Fad dy Neme end See Address �qk� -t U.S.EPA ID Number <br /> Ilof0 \-V -*4 13TH S1 <br /> LjQv (( Ge -cH CA ct01113 <br /> . <br /> Facility's Phone: OO - 0 4'j-+ -11 CPo}Ol`S f69D _I <br /> 9a 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard CMSS,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(i any)) No. Type Quantity WLNot. <br /> t.(}J l 011UQs7� COR ( l vip�I10.S Q� �� �j G"�-r <br /> O v <br /> /1 1 1T'7- <br /> z 2. <br /> 3. ':eMRS TRMF OR REUSE <br /> RECEfVED, OVUTUNOLED �ry ORFD PutSVBSFRUp,1r <br /> _RtusE cRoseY <br /> •.,if RESOIXviRONMkNfAr,PROTECr'rON�ART w ro%1 SUIS N CbN\Tt0'LU`711 <br /> MICE ID,PROVIS INS Orr , °� H <br /> q_ AND STATE REGUTATIUNS. CROs tACT OF 1 a TOGETe wiry{ AI s- <br /> :4JtAQr) ro wCy ro, NAI <br /> AU OF Tw,c Rlbpvmy �+*RE1+cID wA AND Arl wASrE HAS atFir s"R <br /> 14.Special!HaMt-ling InsWctions and Additional InfUma <br /> ortion I <br /> lU ,✓e >aitiUh f{vp"gO`At 4lBa 'tiiu-tr � <br /> i it <br /> 15. GENERATOR'SIOFFEROR's CERTIFICATION: I hereby dedare That the contends of this consign meant are fully and accurately described above by the proper slipping name,and are classified,packaged, <br /> marked and IabeledlplapNed,and are in all respects in proper condition for karepon according to applicable intemationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consgmnenl conform b the teams of the attached EPA AcknnMedgment of Consent. <br /> _ IcetMy lha(ihewaste mnimlietbnafatement iden8fied in 40 CFR 26227(a)(if l am a large quantity ffgalk or(b).(MI am a armed qua bly generator)is he. <br /> Genemtof h Pantedlfyped Name S naNre Monty Day Year <br /> ..+ 16.International Shipments <br /> ❑Import to U.S. ❑Expert from U.S. Pon of enfrylezit: <br /> Transporter Signature(for exports only): Date leaving U.S.: <br /> W 17.TramporterAcknoeledgment of ReoW of Materials <br /> ~oe TranspoM115fifinuffyPed Name Sgnahlre - Monty Day Year <br /> Qrang ner2 Prood Typed Name signature Monty Day Year <br /> ,k 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity, ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 186Akemate Facility(cur Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Fadliys Phone: <br /> W'18c.SglmWredNlemalaFadlily for Generator) Monti: Day Year <br /> 4 <br /> 2 <br /> N19.Hazardous Wade ReportManagement Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. i.4 2. 3. 4. <br /> 1 z4 <br /> 1 20.Designated Facility Cwneror 0perator CerGBoabon of receipt of hazardous materials covered by the manifest except as ndepin Item tell I <br /> PnntedRyped Napre ' f Signature Moth Day Yyar; <br /> EPA Form 8700-22(Rev.3-05) PreviouPeditions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />