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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Erne. en Response Phone 4.Manifest Trackin Number <br /> UNIFORM HAZARDOUS 9 r9. pY p° <br /> WASTEIilANIFEST q:. .7 OilC 9 3 4 FLE <br /> 5.Generator's Name and Mailing Address Generator's,Site Address(if different than mailing address) <br /> l ;liirlte:,'JI UrOked 5C#1tx it EAstna (tea Hr;it) <br /> 17M iivtsls St <br /> IAarltaca. 7 <br /> Generator's Phone: <br /> 6.Transporter ompany Name U.S.EPA ID Number <br /> Ad"Xed CiamicA TraWptart It-_ (SV), GARODC11705A3 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> usNwm6-La Villa <br /> s .�F 11 AAs 5 Beatty <br /> sEr 11 <br /> Facility's Phone: 775,553-= <br /> ga, 9b.U.S.DOT Description(mduding Proper Shipping Name,Hazard Class,ID Number, 1C.Containers 11.Total 12.Unit 18.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLNDI. <br /> NA3092,Hazardous waste,bquicL no-s, (Photo Sill <br /> v x 9,PGI �g�f P 11 51 <br /> 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling instructions and Additional Information R4ecl Nurdw . DDarrw"t Dl&57D9 <br /> 1)ER09171 070137M&.271 MAl-__ <br /> 15. GEN ERATOR'WOFFEROR'S CERTIFICATIONS I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement iderltrfied in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generata ro s nnt_ yped Name Signature t f I nnn a Year <br /> 1� X II i_ f ! t V <br /> -1 16.International Shipments <br /> ❑ y <br /> Import to U.S. [:]Export from U.S, Port of enirylerdk <br /> Transporter siRnature for exports ani' Date leavin U.S.: <br /> IX 17.TransporterAckriowledgment of Receipt of Materials <br /> T p or 1 ri Name ig ''1ur ay <br /> Year <br /> � ► civ �. ., on 1 <br /> ZTransporter 2 Print ped Name Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejecticr <br /> Manifest Reference Number_ <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> LL Facility's Phone: <br /> w 15c.Signature of Alternate Facility(or Generator) Mcr:n Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(I a.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. 4. <br /> 20.Designated Facility Owner or O rator.Celficatior of receipt of hazardous materials covered by the manifest except as noted in Item 18e <br /> Prin d1Typ� Nfme' � � Signature fMon .Qa Year, <br /> 1 <br /> i <br /> EPA Form 8700-22(Rev,AP evious editions are obsolete. `� J DESIGNATED FACILITY TO GENERATOR <br />