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- .. OFF - .n. <br /> Form Approved. OMB No. 2050-0039 <br /> Please print or type. <br /> UtjIFORM HAZARDOUS <br /> I . Generator ID Number age i of 3. Emergency Respo <br /> ManitestTracking Numberp f_,WASTE MANIFEST L. ( � �: U i; "1 } _ ,O `7T20 <br /> fF. �7I -fir=;t K t e <br /> 5. Generator's Nae and Mailing Address Generator's Site Address (it different than mailing address) <br /> (l N m .S t c.- � � . 3 '�•.' . c t c 1 rte ' <br /> )J C7 ,P2 _� -t It I k.1 `: v} <br /> Generator's Phone: J' Lr C) f 'i ' , FIFFIFF <br /> ! U.S. EPA ID Number <br /> 6. Transporter 1 Company Name Mhrli3z (�i ,rlf?OftDaI{�P II tAL '23 Ei��lICES INC. <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address 'r.L,g�)p;; ENVIR I N Ej�'{; 1 E:Ei,leis F y { hjl . U.S. EPA ID Number <br /> fJ �orrr,�r :tr�r1=��.n <br /> s:r <br /> V515 f�30UTH RIVER PO4 <br /> 't<;fE9T SACRAfvli"I� (it Giek 0515911 <br /> IFIF <br /> Facility's Phone: `�1 �` <br /> gap 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 WINoI. <br /> IRWIN <br /> 1 . IlION RCCA HN.7AR00Uri 1{Vr4- L ' t ftat-li (COIL`! 1 !•,ieR) <br /> O ' `rte �J <br /> IF <br /> Z - 2. r1f ,n a <br /> W t -IF <br /> 0 _- E <br /> 3. IF fU ( <br /> IF <br /> FEN v pop <br /> -14. Special Handling Instructions and Additionai Information ' <br /> 1) ER ! 71 <br /> H;3S110LERS TO BE TRAINED AND 1J ' E APP;2MFEG PPE. <br /> E.4?4 GQ ii RA%GT0R: RFA41A.3S 7M OAR:uNINFEW�L Fa�`nr<JIM <br /> 154 GENERATOR'S/OFFEROR'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 labeledlplacarded; and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations: if export shipment and 1 am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 26127(a) (•d I am a large quantity generator) or (b) (f I am a small quantity generator) is we: <br /> GeneratoeslOtferoesf Printedd ryped Name ( SggaCure j� f <br /> Month Day Year <br /> Cm <br /> E 16, IntemabbW61 Shipments ;lj <br /> import to U.S. Export I U.S. U P <br /> ❑ ort of entry/exit <br /> ' Transporter signature (tor exports only): Date leaving U.S. <br /> W 17. TransporterAdmowledgment of Receipt of Materials .' <br /> w Si afro t Month Day Year <br /> Transp AL1 Printedlryped (Jame . _mayOpp <br /> t <br /> CL A <br /> Z Transporter 2 Pdnted/ryped Name Signature " Month Day Year <br /> F- <br /> 18. Discrepancy <br /> 18a, Discrepancy Indication Space Quantity F] Type ❑ Residue ❑ Partial jZejection ❑ Full Rejection <br /> Manifest Reference Number. . <br /> 18b. Altemate Facility (or.Generalor) - U.S.-EPAID Number <br /> V ' <br /> FadliVS Phone: Month Day Year <br /> W 18c. Signature of Alternate Facility (or Generator) <br /> a <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (1.e:, codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 • 2. 3. 4. <br /> 20, Designated Facility Owner .or operator. Certification of receipt of hazardous materials covered by the manifest except as ndd in Item 18a <br /> Printed/ryped Name _ Signature / ' tp Month Day Year <br /> EPA Form 8100,22 (Rev. 12-17) Previous editions•ire obsolete. ` _,^^ . , ^�^ T, ,.. . . ` MT ^'� r. ,^T^„^ter DESIGNATED FACILITY COPY <br /> 800111 ���n <br />