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Plaaca mint or tune 1Fnrm desinnPr1 fnr ice on elite 112-nitchl Noewdler.) <br />Form Approved. OMB No. 2050-0039 <br />EPA Fo-rMS700-22 (Rev. 3-05) <br />Previous editions obsolete. <br />J?" FACILIV O GENERATOR STATE ff REQUIR E <br />UNIFORM HAZARDOUS <br />1. Generator ID ylumber <br />2. Page 1 of <br />1 3. Emergency Response Phone <br />4. Manifest TrackinLNNumber <br />1" rs I,� <br />"' <br />WASTE MANIFEST <br />Z- , e. f <br />I <br />t --, - i'i ter , : 'moi"++ ' <br />I, <br />° IL <br />'a. JJK <br />Generator's Name and Mailing Address <br />Generator's Site Address (if different than mailing address) <br />�SA'il'�-� T`�7�: il�'L� "��`' �� <br />7Sl5�iE iJY��.�1 O.3v�d .� �S $•::J <br />n�y�.s <br />CIA 95547 +r . Jt A± uFS +:2-N <br />Generator's Phone: z--u%e- <br />6. Transporter 1 Cyompaanyy�Name <br />US FPA ID Number <br />icy <br />i':SBUR9 �.:74�?LIFS:��iB 7J� <br />t <br />•'�ti.���!?W� C.rel t"_.^' 10 2 S 27 •' 14 J S <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />•��:..tt**:c=c1ti� 1?'E?� <br />CP :i:b.•v .�'i <br />-��;iilryry4iV�•pi L�tle%� <br />�13.?i+!l.7 THr VEP i�„C <br />!� I'".'7 �3�iRYS_y�:.3.i t!y <br />1� ..`'iJ•M t�� � c; <br />'r ;; ..< •: <br />Facility's Phone: `7 Sr r <br />,.A <br />ga <br />9b. U.S. DOT Description (including Pror <br />'t <br />Shipping Name, Hazard Class, ID Number. <br />10. Containers <br />11. Total 12. Unit <br />13. Waste Codes <br />No <br />type <br />HM <br />and Packing Group (if any)) <br />Quantity WLMot. <br />IAs:,i <br />0 <br />Z <br />2. <br />LU <br />c7 <br />3. <br />PIECEIVEI <br />4 <br />EB 18 2014 <br />14. Special Handling Instructions and Additional In <br />bi-mabon <br />a;?em :LE <br />��< <br />4a- <br />90. ' L �i: 244-03-` HEALTH� <br />1�DEPARTMENT <br />7AUyRMNA>CPA CODES -)La WSiL _'rAP-YOPM "`s :_SOMA'. f�1i.? •S4i r:. <br />15 GENERATOR'SIOFFEROR'S CERTIFICATI <br />N: I 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 labelediplacarded, and are in all <br />espects 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 conignment <br />conform to the terms of the attached EPAAdmowledgment of Consent. <br />I certify that the waste minim¢ation stalemen <br />identified in 40 CFR 262.27(a) (91 am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator'slOfferor Printed/Typed Name <br />Signature ! ^' Month Day Year <br />,^ <br />-j <br />International Shipments <br />❑ Import t <br />U.S. ❑ Export from U.S. PO of entry/exit: <br />116. <br />Transporter signature (for e>tjiags only): <br />e leaving U.Sr� <br />Transporter Acknowledgment of Receipt of Mate <br />als, `. <br />W17. <br />f <br />Transporter 1 Pdnled/Typed N e <br />Signature �) i \ Month Day Year <br />za <br />Transporter 2PrinWypedNa ay <br />Signature' Month Day Year <br />I` <br />18. Discrepancy r <br />18a. Discrepancy Indication Space ❑ Quai <br />lily ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejecion <br />Manifest Reference Number. <br />F <br />18b. Altemate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />tai <br />Facility/s Phone. <br />W <br />18c Signature of Alternate Facility (or Generator) <br />Month Day Year <br />a <br />z <br />N19. <br />Hazardous Waste Report Management Method <br />3 odes (i.e, codes for hazardous waste treatment, disposal, and recycling systems) <br />O <br />1, <br />i <br />2 <br />20. Designated Facility Owner or Operator. Cerbfica <br />ion of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name% <br />Signature ✓ Mont �Day Year <br />�' <br />lis <br />� 7i �+' � ii '�r/ � J <br />:1' j✓f ed r+,�'t � F � 0 � .,':> <br />.f''.. <br />EPA Fo-rMS700-22 (Rev. 3-05) <br />Previous editions obsolete. <br />J?" FACILIV O GENERATOR STATE ff REQUIR E <br />