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D,a.r .,,;.a,,: Jl. lr, .,,e.� r,.IN. fl 2.aml nmeuieerl IM, YNLOIb4i Form ADDroved. OMB No. 2050-0039 <br />EPA Form 870422 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)' <br />UNIFORM HAZARDOUS 1, Gearebr IO Number <br />eAL 9 q -) -71 <br />2. Page 1 of <br />r <br />3. Emergency Response Phase <br />966-933J24 <br />14. ManNael Tracking Num ber <br />001717155 JJK <br />WASTE MANIFEST 0V0 r <br />5. Generators Name and Malitg Addraea Generators SRO Address if ciftent than raPatg address) <br />�,�x tJosle <br />e 2� <br />-2 1, 0 . 1333 r ,E'AJ i -le <br />P.D. box ?4100 I <br />eA 9s�a0 <br />Lod) 64 ?sz�i If Lod ;i <br />Generators Phab: O 1.-S-% l l <br />6. Transporter 1 Canperry Name U.S. EPA ID Number <br />0✓441_e4 e, 4jar a.cA4. YeAaayaQ f L"A �2crOV70S-g0 <br />7. Transporler 2 CoU.S. FPA ID Number <br />Nemo <br />CI.fnNmperry <br />aS aojjt, l e12 `cgs /uA VJ?32asv <br />8. Daei netsd Facility Name and Sibwn�w U.S. EPA ID Number <br />ei.e4, 11ra.'lQ 0 So.3"vse LtL <br />iO21 a4 'r/;ssA !2040 <br />sow 3 -0 -se , eA 95, 3 eA 15 -fq �f 9 q 3 r a <br />Fad' s Phone: 4 1 - <br />9a <br />9b. U.S. DGT Omabllon (Ywktdtg Pmper Shlppbg Name, Head Gen, m Hunter, <br />10. Containers <br />11. Trial <br />12. Unlit <br />13. Warm Codes <br />No. <br />Type <br />HM <br />and Paddrg Gmup(Nem)) <br />OuentNy <br />WWaI. <br />1. i14 lzbi WA *1-0 PA A) 'r 3 , PGS <br />343 <br />X <br />CAov1� r <br />�^� <br />yDo <br />r <br />i <br />Lu <br />2. <br />3. <br />4. <br />14 �peaal Handing Imhw9om and Additional Informal <br />,' 3Zz8?Z; GcL' -Qof(r,erS, D/T;. <br />pRaTrreT ,eA+:..9 4 ! �✓C702Z <br />15. OENERATOR%WFMW$ CWrF1CATION: I Mwby decks tlW the CdnWlh of this comootmed anNYy and amaamy described above by the Proper s *0th name, and are Paull packaged, <br />marked and labeledrphovded, and am Is d nepech In pmperoondillon for transport i 000 di g to applicable hhmetlmal and national govemmenel regulations. N export shipment and I am the Primary <br />Expodar, I aNy tlW tlw wnMlp d tea mmlpmNnd oodam ben llama of aftsded EPAAcknowAdpard olConeed. <br />1 any tat the wage mNmalalim deeesal Idended F 40 CFR 28227(a) (If I sm a hge puldly gnmebr) a (b (NI ern a and quntlly Is oue. <br />GeneretolsiDlhror yped Day lYeQv <br />�� v/ <br />—s <br />{— <br />16. International Shpxrrnh <br />EJ few be U.S. 5Wfran U.S. Pat orwevsxR <br />Z <br />Transporter slgnabae(for exports arty): Dem kavng U.S.: <br />17. TanapalerAdoawWidynad d Realptd Meeridg <br />Year <br />Tmwr IfktdTypt sayaNa Month � ar <br />a <br />-{F <br />QTransporter <br />2 Pdn yped Name S' Month Day Year <br />AWAXe2 lop -ow <br />♦ <br />18. Discrepancy <br />18a. Dlacraparxy IrMkaaon Spec ❑ aanay ❑ Tw. ❑ R.W. ❑ Patiet Rejection ❑ FWI ft.pden <br />Manifest Reference Number. <br />18b, Alternate Facility for Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />w <br />18c. Signature ofANemam Faalily(or Generator) <br />Month Day Year <br />Q <br />Z <br />w1g. <br />Hazardous Waste Repot Management Methal Codes (i.e.. codes for hazardous waste treatment disposal, and regaing systema) <br />3. <br />4. <br />20. Designated Facily, Owner or Operator. Cerb7kalbn ofreceipt ofhmnlous materials covered by the manifest except as ruled in Item 18a <br />1 <br />Pnntedrryped Name( I malum l MMonth pay Year <br />�` <br />Gv\A. i Ol` <br />EPA Form 870422 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)' <br />