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Please pnnt or type Form Appreved DMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Gennterator tD Number 2 Page 1 of 3 Emergency Response Phone r 14.Manifest Tracking Number <br /> WASTE MANIFEST C/�1- 3��f aTS� ! �zA7 �'7�_S!1"T 0149, 676694 J J K <br /> 5.Generators Name and MaiTng Address 1I Generabp Site Artdneis{rf ditfcrent than maiEng address) <br /> ark{ qy,f-.E7 1y 54oc(Zion r�gr.20 a S4r_�c}zq�m a <br /> Generals Phone. <br /> 6.Transporter 1 Company Nampa ! U.S.EPA IDD Number <br /> !� <br /> V t iCC�rc-[/'T' 70/ <br /> 7 F nsporter 2 Com Name U.S.EPA ID Number <br /> ^ i <br /> .hill <br /> 8.Designated FacLty Name and Site Address /,sti r~Fr�fle` <br /> U.S.EPA ID Number <br /> acTiry Phare: CIVL 6W a Wry q <br /> 9a. 9b.U.S.DOT Description(mduding Proper Supping Name,Hazard Gass,FD Number, 10.Containers <br /> HM and Packing Group(rf any)] It.Total 12 Unit 13.Waste Codes <br /> 1. <br /> No. Type Quantity VtrtlVal. <br /> C <br /> z 2. <br /> LU <br /> 3, <br /> 4 <br /> 14 Speaai Handling Instructions and Additional Information <br /> 17l <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: i hereby declare that the contents of this censigrunent are fully and accurately described above by the proper shipping name,and are classified,packaged <br /> marked and labeledlpiacarded,and are In all respects in proper condition for transport aaordug to ap*Bble intemationalaW national 90verrmrentaf regul3tl0m.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment comm to the terms of the attached EPAAcknoMedgmentof Consent. <br /> I certify that the waste minimization statement kfenged in 40 CFR 262.27(a)Cir l am a large quantity generator)or(b)(ill arp a small quantity generator)is hue <br /> Ge�&!offerors Prrtded/TyperIa � Mo <br /> �lame SRr <br /> nth Day Year <br /> -s16.Intematlorsai Shipments Import <br /> • - � <br /> Transporter ' nature foronly <br /> ❑Import m U.S. F LiExpert from U.S. Port of entrylexlt <br /> ( exports ontyi' Date leaving U.S.; <br /> IZ 17.Tmnspo terAcknowbdgment of Receipt of Materials <br /> LLJ <br /> 0 Transporter rintedffyped Harrp j Signature <br /> CL <br /> }/f (J Q Manch Day t Year <br /> for---cyA�G > t I f r <br /> a Traasporter2 PrintedlTyped Name Signature t <br /> ji <br /> Month Day Year <br /> ~ 18.Discrnpanry � )l� U 1 �. ' �. .',1 I' •'ti <br /> 78a.Discrepancy indigtian Space <br /> ❑ Quantity ❑Type ❑Residue t.' ❑Partial Refection ❑Fu9 Rejection <br /> 18b.Alternate Facility ar Generator, Manifest Reference Number: <br /> -� U.S EPA D Number <br /> U _ <br /> tQi Faci3tys Phone <br /> tau 1 tk Signature of Astemate Faa„ty(or Generaton <br /> zMonth Day Year <br /> 07 19.Hazardous Waste Report Management Method Codes ri.e.,codes for hazardous waste treatment.disposal,and <br /> C 1 2 recycling systems, <br /> 3 4• <br /> VSD,Designated <br /> PrirsiedlTyped Naame me Qwner or Operator 22catien of reCeipi of hazardous materfats covered by the manifest except as nded in!tem I8 <br /> I9P <br /> Signature Month Day Year <br /> A FormF8700-22(Rev 12.17) Previc,.s ed:trons ar'e obsolete <br /> TRANSPORTER COPY <br />