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o�;.� ��� ..��.<<< �_ _��. :� __ -�-� -��-�'�-�•6 �.� ^ter ,. . <br /> Please print or type.(Fo desigped for use on elite(12-pitch) pewriter.) Fonn Approved.OMB No.2050-0039 <br /> t UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> -WASTE MANIFEST G �0o 0 Z-2 ('6 1 son 424-9m 010198887 JJK_ <br /> 5.G,g(�eratol ame and Ma Address/ Generators Site Address(f different than mailing address) <br /> t od;I GA q VI-i f° <br /> 1' vl �c�. <br /> Generator s Phone: L C)°i' L(4f �Z <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> FREMOUIW ENVIRONMENTAL SERVICES INC ICAROOO 1 7 1 :0 1 7;, <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address �% U.S.EPA ID Number <br /> US ECOLOGY INC <br /> HVVY 95 19 MI S OF CY 16 ACRES <br /> BEATTY WN 83II03 <br /> Facility's Phone: 77,ci r,r,,-A_ N V T 3 3 0 0 1 0 0 0 0 <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> 9a. P• ( 9 Pe PP n9 11.Total 12.Unit <br /> HM and Packing Group(ii any)) No. Type Quantity WtNol, 13.Waste Codes <br /> O 1Af ,��1C�1� l��vs-1� •C <br /> - w <br /> 2. NOi�-RCRA HAZARDOUS WASTE,SOLID(OILY DEBRIS, 223 <br /> ABSORBENT) OK -z f <br /> 3. ' ti'r.K._,t,e j <br /> MAY 11 2016 _ <br /> 4. <br /> R4,..'jrm1, <br /> 14.Special Handling Instructions and Additional Information , Y <br /> ERC�B979 S-G 0701283Qa-SS39 -Olfy Q�ttris <br /> C r) W n ►Y Ckc A =I-'- N) '1 HAMIERS TO HE 40ffit TRAJMM AND USE PPE. <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully 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 /> Eicporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is we. ` <br /> Generatofs/Ofleror's Printedffyped Name Signature Month Day Year <br /> _J 16.International Shipments Import to U.S. entry/exit: yY <br /> I- ❑ ❑Export from U.S. Port of <br /> Z Transpporter.signature(for exports only): Date leaving U.S.: <br /> J 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1-Printed/Typed Name Signature Month Day Year <br /> a Transporter 2 Printed/Typed Name Signature Month Day Year <br /> st <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑_Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U _ <br /> na+ Facility's Phone'' <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(.e.,ardes for hazardous waste treatment,disposal,and rung systems) <br /> LLJ <br /> C3 1.. 2. 3. 4. <br /> r <br /> 20.Qesignaled Facility Owner or Operator:Certification of receipt of hazardous materials cave , by the manifest except as noted in Item 18a <br /> Prmted/Typed Name r Signature v tdQOtl1 Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGN A r TO GENERATOR STATE (IF REQUIRED) <br /> 12171.1094 <br />