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Please print or type. (Form deskyied for use on eft (12 i) ) Generator <br />Form . OMB No 205MM9 <br />EPA Form 870 0-22 (Rev. 3 iYa Pre ' s are . <br />' c` - 44 ': <br />UNIFORM HAZARDOUS L ID Number <br />t En)ta <br />2. Pam 1 of <br />3. Phoce <br />(-... "•T*>,003710292 <br />4. T Number <br />FLE <br />WASTE (FEST <br />5. Gernerator's Name and Site`Addiesa (if Owerit durn malling address) <br />n .Lk, r TRUCKINQ INC <br />509,21 FFfW.T ST : 1''? trig. D +. <br />2 rafU ) (root? <br />- <br />Generators Phone: P-99 h M <br />6. renspormr Name U.S. EPA � <br />Ta <br />7. Transporter 2Gomparry Name U.S. EPA ID Number <br />8. Designated Facility Name and Sit'eAddress <br />1N TY—V SYSTEMS" INC. Us ram <br />... <br />17Z --P C I ' PENTAD <br />y <br />l ea TLIN, -f-x <br />FadWs Phone: <br />9a. <br />9b. U.S. DOT Description (in&*V Proper ftpmg Name, Hazard Glass, ID MBTdw. <br />10. Containers <br />11. TOW <br />12 Unit <br />13. Waste Codes <br />No, <br />Type <br />HM <br />and Packing Group (dany)) <br />Wt1Vd. <br />0 <br />(ARS19PIWW, AND OT -L) <br />3. <br />4. <br />14. Sped Handling kn1ructiorts_ and Additional kftmafion <br />1 R Al z .. .% ..4 P'.. <br />Rx..141 - T r4 .- '.. I q 'QJA V T i'JARP t B' ROS g 41 A7 4147 <br />15. GENERA7101t' S CERTIFICA • t hereby declare that the contents of m consignment are by the proper stftingnom, and are clasAW, <br />marked and rded, amd are in all respects m pmpar condrion for transport accordingto applicable mirrmational and raborial 9wiernmental regulations. 8 export dupmrd and 1 am tt Primary <br />BWrtar, i cm* #W the contends of flus crmsomumt conform to the terms of ft allached EPA Acknowlerignat of Coraert <br />I certify Brat the waste mnnimization statement ideffed in 40 CFR 26227(a) (d I am a or (b) (if t am a small quantity ) � tore. <br />d yped Name . tl ear <br />J <br />h <br />16. International Shi;mvents , <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit; <br />Z <br />T foL : ..Date U.S.: r <br />17. Tm sport;r of Rec* Of Materials} <br />Transporter 1 drdetl(fypedto.r ear <br />y <br />` <br />Z <br />Q <br />_—, ;.—emonth Day Year <br />Trensp tedffyped<Name SUM"--- <br />18. Discrepancy <br />18a. Discreparq Indication Space ® Cknantity ❑ TYPa ❑ Residue ❑ Partial ❑ Fun Rejection <br />Mandest Reference Number. <br />18b. Alternate Facility (or ) U.S. EPA ID Number <br />t:7 <br />` <br />facift s Phone: <br />W <br />18e. Signature of Allamata Featy (a Generator) Month Day Year <br />Q <br />z <br />19. Hazardous W Report Management Aftlhod Caries (Le., codes for hazardous waste -treatment, disposal, and tecycliq system) <br />T, <br />4. <br />20. Designated Facility Owner or Operator Cerlificaticin ofrecWof hazardous mallervilscoveredby8he mardlesit oweptas noted inNam 1 <br />Rintedffyped Name Signaffe Month Day Year <br />EPA Form 870 0-22 (Rev. 3 iYa Pre ' s are . <br />' c` - 44 ': <br />