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— ----- -----............. <br /> - — <br /> Please PrIfitatype,(Porrrt'des'Igtted for use ort elite{12 tdi)'t ge tter}.1-:0J9594117' :�P 14120$� Famr�pproved.O�IB�To,2050 O'>339' <br /> 'UNiF0FIIN H,AZARE)t1US 1.Generator ID Number Z Page t of 1 Emergency Response Phone 4.ManifestTraeldNber <br /> WASTE MraIViFEST .�.: 0 .�> ra0067 um5 8 8 3? F ,E <br /> S.Ganerata'sName and Mailing Address. Generator"s•SiteAddres(if diffemerit anmailingaddress) <br /> 9k-doserth���fedicai�errt�r:r <br /> i966_H:-601fornfa'-st SAME, <br /> GenerafceePhMa:f2O9k i1-522 ATTIC-Ravmond$eias <br /> 6. ransp e—r- piny Name U.S.EPA ID Number <br /> Clean.Haftm Environmental S'ettvices.fit>ic J.-KA-1303'922:2.9-50- <br /> 7. <br /> ..KA l303'R22:2.x.50A.,7.Transporter 2 Company Nam U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Aragonite.= �T������ �� €7 <br /> 11600 Na�eti'sE;Aotus Road <br /> iarants, ille.UT 84029 <br /> Facility's Phone: <br /> ga. eb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit 13.Waste Codas <br /> HM and Pee"Group Cd any)) No. Type Quantity wul/oL <br /> tY 1 0 7_HAZARDOUS 0U9 dal TE. Ol.l1 .l -O.S..f CETONE1.9. $ p 181 F003 <br /> X 111 L <br /> Uj <br /> 2. <br /> 3, <br /> 4 <br /> 14.Special Handling instructions and Additional Information <br /> �Y, <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that Me contents of this consignment are idly and accurately descdbed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledfplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmentai regulations.if export shipment and I am the Primary <br /> Exporlor,Ice*thatfhe contants ofthis consignment conform to the terms of the attached EPAAcknewledgment of Consent. <br /> I certify that the waste min' ' 'n statement identified in 40 CFR 26227(a)(d t am a large quantity generator)or(b am a small quantity generator)is true. <br /> enerato ro s FrimediTypso Name Ngnaw Monthy ear <br /> H 13 <br /> 16.International Shipments ❑import to U.S. ❑Export from U.S. Pat of entry/exit <br /> T ern ' hue for exports only): Date ieavin U.S.: <br /> 17.Transporter AcIczawledgment of Receipt of Materials <br /> Transporter 1 Pdnted(fyped Name re Month Day Year <br /> N <br /> ze2, Transporfer2 Printed/iyped Name Signature onThy ear <br /> 18.Discrepancy <br /> 18a.!Discrepancy Indication Space ❑ Quant ❑Typ Residue e ❑ <br /> Quantity ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 4. <br /> �- <br /> Fac&s Phone,, <br /> 18c.Signature ofAltempte facility(or Genarator) Month Day Year <br /> 19.Hazadous Waste Report Management Method Codes p.a.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by tate manifest except as noted in item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 871)0.22(Rev.3-05) Previous editions are obsolete.- _ - .. . DESIGNATED FACILITY TO DESTINAmTiON STATE(IF REQUIRED) <br />