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Please 'nt or form desi reed for use on elite 12- itch) writer.) FormA pro ed. IOMB INo. <br />( ( P <br />05-039 <br />2050-0039 <br />UNIFORM HAZARDOUS <br />1 1 Generator ID Number2. <br />Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />000127349W <br />WASTE MANIFEST <br />4 JS <br />(BOO ^ 12:L1 <br />S <br />5. Generator's Name and Mailing Address Geenerator's site Address fd different than mailing address) <br />Sir%J% `inti t <br />I® <br />pl® A.,--fm*t,Jr'f ��Ge�"i G �i <br />57velt.1bWj C* 9152O-1 §-jOGIGToti d G•4 9cio-7 <br />Generator's Perone: <br />6. Transporter Company Name U.S. EPA ID NumTer <br />River <br />R6ive �� L45nj 114 <br />7. Transporter 2 Name U.S. EPA ID Number {� p <br />-Tnt. <br />TC i 4 N S ! �J! <br />8. Desgnat Fad Name and SiteAddress U.S. EPA ID Number <br />Z-{C- t�ev;rpvt�w l-►uf+r' Srtvle�e s LL G /�?-�Q�'61�70S4i02 <br />2ssy 51W-ey WD <br />cot-A, d' <br />I e, , Az_ L s-2-7- <br />Faci" sPhone: L524 72 j, — tGs <br />9a, <br />9b. U.S. DOT Description (mckxling Proper Stripping Name, Hazard Class, ID Number, <br />I <br />10. Containers <br />11. Total <br />12. Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group fff any)) <br />Quantity <br />WI.Nol. <br />1. e �� �, , 2.1 ` rAZ % , 6" 1* K <br />O <br />G� <br />G <br />LAJZ <br />2. Qq tuMlQq,5 5� te✓ �{t�rA-4b/'G L�ufds, N®S, 3�P47 <br />33 <br />tom) <br />►C��cco P <br />eF <br />3. ,VN If t, aCFF0 7 W 4Y, Lid -d3, 4 1,. 4Wa, <br />3"31 <br />vtz I <br />m14 <br />2,3 <br />ICF" p <br />! <br />GF <br />ad <br />p <br />14. Special Handling Instructions and Additional Information <br />3.4j- G W. Q-,b <br />PfY �� � <br />" ► <br />�L vY 4-1 <br />INC-y(3 <br />1 ArGY3 k- &s <br />I x I SAF <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labelediplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If expel shipment and I am the Primary <br />Exporter, I certdy that the contents of this consignment conlGrm to the terms of the attached EPA Acknowledgment of Consent. <br />I cerf1y that the waste minimization statement identified in 40 CFR 262.27(a) fd I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />pr eror sPrintedrVarn signature Month Day Year <br />-j <br />16. Intemational Shipments Import to U.S. ❑ Export from U.S. Port of erdrylexit: <br />Transporter signature for exports 22t Date le U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />- igna on ay eat <br />Print ypTW4 <br />Tr79, <br />Fpm <br />V) <br />/1 <br />{ 4• 'I I <br />Z <br />Tr&Lqxxter 2 Printed/T ed Name gna - ay Yedr <br />Lac <br />u, rtt, I C� o <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity - ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />V <br />L& <br />Facili 's Phone: <br />W <br />18c. Signabxe of Alternate Facility for Generator) Month Day Year <br />Q <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., cafes fox hazardous waste treatment, disposal, and recycling systems) <br />® <br />1. <br />2. <br />141N% <br />I M18A11Ud <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pnmedflyped Name Signature ,� Month Day Year <br />Ve.J of 1,2A 10q <br />EPA Form 8700-22 (Rev. 3.05) Previous editions are %solete. DESIGNATED FACILITY TO DEST71014 STATE (IF KF.QUIREU) <br />