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+�11..3 `i ,rl.( <br /> Please print or type.(Form designed for use on elite( 2-pitch)typewriter.) i+.. i'f"f% Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4. Vif <br /> WASTE MANIFEST C A .1 Cin 4 U `j !i ts luQe C <br /> F L EU[ <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Stttt�,tttttlt'_i(? il�;�'t',iYit'.�Ld1t i <br /> J94 4 N.FI Pmi♦f Drive Artt-� fwt 1 ;etttsi+4r <br /> LAuakUitl,C A"Pt,20!J <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name _ ;_. __ - U.S.EPA ID Number <br /> t'ieixt H-v6ats Enr4nanivtit41 S ;vine.Ini: s M A D 0 3 9 312 2 2 S 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 4AN 11. 20,16U.S.EPA ID Number <br /> C-10iml,111VfYOfX Arammlitc!I_l <br /> 11600 NurtttANttu Road 1.!I V 5 K 1 K 5 2 1 7 7 <br /> U aiAtsr{�I+r,01 84029 E'NIVI!�OR���!!ENTk! <br /> Facility's Phone: <br /> N3%1 OM-800 I�r!�+TlJ P+CQnpT�1�f\rr <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WWoI. <br /> 1. ROR WAA WARMIS W 511 L1IQUIDS,0DRMA11-IN) 3�1. <br /> 0 <br /> 0 bC, I D o0132 P <br /> a <br /> LU <br /> Z 2. <br /> W <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handlingructions and Additional Informa on i <br /> � Instructions uc^c k'� �1�21U <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:.1 hereby declare 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 respe 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 terns of the attached EPA Acknowledgment of Consent. <br /> I-certify that Ute waste minimization statement Iden fled in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's Offerofs Printed yped Name gnature Month Uay ear <br /> k IT-ChY .. r t� M lVV <br /> E, !t. s f '� `- I <br /> =a 16.International Shipments �? <br /> F- ❑Import ta.U. . ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> T nspv 1 Printed/Type�Name , gnature 7 E / on ay ear <br /> k�j-�� �S'"14tNI(4tN� I ,f' , li I Det I l <br /> Z Transporter 2 PrintedIrTyped Name SignMonth Day Year <br /> Q <br /> F- <br /> 18.Discrepancy <br /> 18a:Discrepancy Indication Space <br /> ❑ Quantity El Type 11 Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> a <br /> LL <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q � <br /> z <br /> 19.Hazardous Waste Report Management Method Cod's(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ 1 11040 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are bsolete. GENERATOR'S INITIAL COPY <br />