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571 <br />Please print or type. Form designed <br />for use on elite (12 -pitch) typewriter.) - <br />Form Approved. OMB No. 2051}0038 <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />2. Page 1 of <br />1 3. Emergency Response Phone <br />4. Manifest Tracking Number <br />000039843 DAT <br />r- <br />R7 , 577 -?66d <br />5. Generator's Name and Malling Address Generator's Site Address ('rf afferent <br />than mailing address) <br />uIAN ;.ttDWIN AIRMW SAN 3U€IOUIR AIRIORT <br />S900 3IRPORT MY SON MOOT NY <br />Generator's Phone: 113TOCCON CA Mah: r' + - r T t <br />) -r- r` . <br />6. Transporter i Company Name <br />U.S. EPA ID Number <br />ConContury Environmental me P1 nLP <br />CAR 2 06' <br />7. Transporter 2 Company Name <br />U.S. FPA ID Number <br />8. Designated Facility Name and Sita Address <br />U.S. EPA ID Number <br />SYS s EC14 ENVIROW.'r-YtTAI <br />1420 MTH CFAENT ROAD <br />Facility's <br />Phone: (= e(,WT10, XS ES ` W))) 373-4451 <br />! 'lJ9Et'r33 <br />59 <br />ga <br />9b. U.S. DOT Description (including ProperShfpping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12- Unit <br />13. Waste Codes <br />HM <br />and Packing Group (if any)) <br />No. <br />Type <br />Quantity <br />WLNol. <br />1. )r`RIPM FUWAILE 1.10113 NOS iPRIIFFINE GLYCOL) 3 PHI <br />X <br />D1'1 <br />175 <br />Ao�1 <br />Z <br />2. <br />LU <br />3. <br />AU <br />G 22 014 <br />4. <br />' <br />14. Special Handling instructions and Additional Information <br />ii.) VE001132fi-09 - FfT i28; liii"_X FUELUFFiRC! P1 <br />4A 1B <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fury and accurately described above by the proper shipping name, and are classified, packaged, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attac'red EPAAcknowledgment of Consent. <br />I certify that the waste minimization statemen(Identfied in 40 CFR 262.27(a) (if I am a large quartly generator) or (b) (if I am a small quantity generator) is true. <br />Generators/Offerors Printed/Typed Name Signature <br />Month Day Year <br />5 Q�U <br />Z O <br />16. In ernatlonal Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. TranspvWAcknowledgment of Receipt of Materiels <br />T rt er 1 Prirde yped me S n re <br />Month Day Year <br />0. <br />6 I r <br />za <br />Tra r yped game � Signatu <br />Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space [IQuantity ElType ElResidue <br />❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J_ <br />rJ <br />w <br />Facilitys Phone: <br />18c. Signature of Alternate Facility (or Generator) <br />hbnth Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1. 0 <br />L4 <br />Z <br />3. <br />4. <br />20. De nated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest exce t as noted in Item 18a <br />Prim ype Sign <br />Month ay ear <br />4 <br />-4 S k - tf 4* <br />EPA Form 8700.22 (IRK. 3-0f Previous editions are obsolete. D S TED FACILITY TO DESTINATION STATE (IF RE UIRED) <br />J <br />