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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man s rakinj NeTbAr WASTE MANIFEST CAL 000 286 540 1 610-541-2125 `4 u `� " � ` F L E 5.Generators Name and Mailing Address Generator's Site Address(d different than mailing address) �nitt2rl::ia!ti t_+im3rer •int s �v;c,r,r1'.t�,.y rUsn.r'.U��`it� GereratorsPtwrre: 209-22A i/00 6.Transporter 1 Company Name U.S.EPA ID Number Btq Sky Envilmo mental St)lunions CX000:3�16010 7.Transporter 2 Company Name U.S.EPA ID Number VO Industrol Servico NIR 435 042 74;1 8.Designated Facility Name and Site Address U.S.EPA ID Number U5 Ec-nln•ty ligttaeyl.•t. 11 WyNV1301r. --aa'ty's Phone: 776-653-2201 NVF130010000 ga 9D.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HY and Packing Group(it any)) No. Type Quantity W1 Nol. t l a Non-RCRA Hazardous Viaste,Solid (U<>bris) W 2 3. i� I 1 {i nstn,cbons and Addili ',1nf �cn L , y ►'roFga V 07012E-300-7510 Fh1ERGCNCY CONTACT .TEFF RHODF`' 15 GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper snipping name,and are classified,packaged. marked and labeledlolacarded,and are in all respects in proper condition for transport according to appliciA international and national governmental regulations.If export shipment and am the Pnmary Exper,er,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certfy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ff I am a surae quanbly generator)is true. Generaloes'Offeror's PrintealTyped Naipe, Signature Month Day Year J 16 International Shipments F— ❑Import to U.S ❑Export from U.S. Port of entryiexrt Z Transporter signature(for exports only): Date leaving U.S.: W 17 Transporter Acknowledgment of Receipt of Materials I— Transperler 1 PrinledrTyped Name c' Signature ! Month Day Year Z Transporter2P ed Typed Name Signature r Month Day Year t- 18 Discrepancy 18a Discrepancy Indication Space13 ❑ Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejectron Man fast Reference Number: 18b A;terna:e Faal;ry(cr Generator) U S.ERI ID Number J V ' U- Fa-;lily's Phone: W '8c Slcnalu'e of Altemate Facafty(or Generator) Month Day Year a z 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1- 2. 3 4. i 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrirledTypedName Signature Month Day Year EPA Form 8700-22(Rev.12.17) Previous editions are obsolete. GENERATOR'S INITIAL COPY