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Please print ort W.(Farm designed for use on elite(12-pitch)typewriter) FormApprwad.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.GeneratorID Number 1 Pape 1 of 3.Emergency Respome Phone 4.Manifa t rackfog Nwnber <br /> WASTE MANIFEST —•-—————--— ' Ji K <br /> 5.Generatces Name and M ' gAddress Generator's Site Address(ff different than ma&rg address) <br /> - ENTO) <br /> ti�kL:►4+i+�_t 1TOw CA x&28 CA � 829 <br /> GeneraVDes Phan: 918 423-3279 <br /> S.Transporter 1 Company Name U.S.EPA ID Number <br /> 'MRONMEWFAL.SERACES ?8277036 <br /> 7.Transpcner 2 Company Name U S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> A4ilHsL "J. srLrr}+'rIi -1 THSTRM <br /> 'AF.-I�'N A- t3t6 W AZR00000242E <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Desaiption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.UNt <br /> HM and Packing Group{!f any)) No. Type Quantity WUyd, 13.Waste Codes <br /> Y:A—i- Uq-jii+ i�.Le k iA.rhe <br /> w <br /> ea <br /> 3. <br /> 4 <br /> 14.Special Handing Instructions and Addi Information <br /> - . ,- ,,.T"TACT :Hf M_: -C 1-41W-4 24-93M WOTIE IML OKOH KAERGif Ia1:1T1 *PROFILE t!I SB2 GW <br /> - <br /> COPPER *EMERGENCY CMITACT Ci iEMTRcC 1.80"24-93W*APPROPRsATE PERSONAL PROTECf'IYE•EQUIPMen <br /> 1 t. <br /> 9/33 17 2-0c-I40 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of t is consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacmded,and are In ata respects in proper condition for hanspod according to applicable intemaltonaland national govemmental regulations.If sN <br /> export Omani and I am the Primary <br /> Exporter,i certify that the Conterb of this consignment conform to the tem of k attached EPAAdumwladgment or Consent. <br /> I certify that the waste minimisation statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(N I am a small quantity generator)Is hue. <br /> GeneraiceslOfferces PdnledlTyped Name Signature Math Cly Year <br /> —i 15.Intemabonal sntpments <br /> ❑import to U S. ❑Export from U.S. Part of entrylexit: <br /> Transporter signature(for exports only): Data leatirrg U.S. <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> O Transporter 1 Pdntcnr7ypgd Name Signature Month Day Year <br /> lr' . <br /> Transporter 2 P&tadrryped Name Signature <br /> March Day Year <br /> 18.Discrepancy <br /> 18a Discrepancy InScation Space ❑ Quantity ❑Type ❑Re,Idue ❑Partial Re .&. ❑FW Rejection <br /> Manliest Reference Number <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> ii <br /> LL Fadilism*ne• <br /> o lac Signature a Altemate Facillly(or Generator) lay Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(Le,codas for hazardous waste trealmeM,disposal,and recycling systems) <br /> p 1• 2, 3 4. <br /> 20 Designated Facility Owner or Operator Certification of receipt of hazardDLS materials covered by the mandest except as noted in Nem tea <br /> Fin; yped Name Signature ay ear <br /> EPA Form 870022(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />