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-0 <br /> Pie se print or type:(Form,designed for luse on elite(12-pitch)typewdler.) _,Y, Form Approved.OMB No.2050-0039 <br /> Generator 2:pbgel of '3 Emergency Response PhoneanifeatTracking'Number <br /> UNIFORM HAZARDOUS eratorTD—Number <br /> i J J K <br /> :WASTEMANIFEST ' C k, L 0 ,,D �4 I <br /> 01 0.41r <br /> 5.,Generatoes Name and Mailing Address."- GeneraI&AjSite Address(If different than mailing address) <br /> TERN TRUCK GENITrnc WESTERN TRUCK CENTER <br /> PO BOX 3200-0 �3 S.I <br /> ST 0 C KTO N'C A 'a�,'25 2 i S10"71,4C(ON CIE, C15215 <br /> Generators Phone: 2 C" a 12 T Z 0 <br /> 6.Transporter I Company Name - U.S.EPA ID Number <br /> FRF_1Vi0tJVV1S;F__,1Rv1GE S IN11 C, 1, R G C 1 0 <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> ASBUI-W ENVIRONMU—NTALS(:_;rV1C F—S, AD0282770 3 6 <br /> 8,IM <br /> V41110ME-RDOOa d Facility,Name and Site Address U.S.EPA ID Number <br /> N <br /> M <br /> 20DO-1-411 ALAL�Mfi-,-ST[:,EE'I* <br /> Facility'sPhons: G A 1 0 0 1 3 9 5 1 2 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No, Type Quantity. wtivol. <br /> f. D00i: DO'18 3-4-�'r <br /> 0 <br /> 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Ins1rucliogs and Additional Information <br /> ERGV <br /> R'ki'mrau TO TA nom:� <br /> 115: 'G.E[4ERATOR'Sl6FPEROR'S*CERTIFICATIO.N: I hereby declare that the contents of this consignment are fully and accurately described above by the propet shipping name,and are rA*as41fied,packaged. <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable International and national regulalloni.'it expel shlprnert andJ arin 0)e Prlffiary 1.4 <br /> Exporter,I certify that Ste contents of this consignMeni conform to the terms of the attached EPAArknowledgment of ConsqnL . <br /> I cerfllyl4at the waste,mInImIzelion statement identified In 40 CPR262.27(a)(it I am A large quantity generator)or(b)(it I am a small quantity generator)Is tiva.. <br /> Oeneraloes/Offeroes Printe0frylped Name Signature_ Month D#.�'. Year'i- <br /> 116.1nternallonalShIpments <br /> EJ import I.U.S. EJ Export from U.S. VO4 of-entry/exit: <br /> Transporter signali5fe(for exports only): t Date leaving U.S.; <br /> L Df 17.Tr6nsporter Acknowledgment of Receipt of Materials <br /> Ll ' , <br /> Transporter I PfintedfTyped Name Month Signature Day Year <br /> 0, <br /> ­�,i t­ovl A,.) <br /> Y' <br /> M Transporter 2 Printed/Typed Name SIgnidqq_, Month Day Year <br /> F <br /> 7� <br /> y <br /> 18.Discrepancr <br /> 18a.Discrepancy Indication Space ❑ Full RLIectiiin <br /> [:1 Quantity El Type-• Residue El oarval Rejection <br /> 'Manifest Reference Number., <br /> 18b;Alternate Facility(or Generator) U.S,EPAID Number <br /> F.CiRys Phone: <br /> LU, 18c.Signature ofAlterriale Facility(or Generator) Month Day Year <br /> S2 19.-Hazardous Waste Report Management Method 0-odes(i.e.,codes for.hazardous waste treatment,disposal,and recycling systems)C13 <br /> • <br /> 01 1 2, 3. 4. <br /> 120!Designatea'Facility Owner or operator:Certification of receipt of hazardous materials covered by ffie manifest except as nded In Item 118af <br /> Printafflyped Name" � Signature Month Day Year <br /> .1 r, It I � t-d �L �/ <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> DES&ATED FA " TYTO)*NER;�TOI!STATE(lF,Ft'EQUWEd)' <br />