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Please print or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved.OMB No.205040 <br /> UNIFORM HAZARDOUS 1.Generatoi ID Number 2.Page 1 of 3.Emergency Response Prone q 4.Manlhrt Tracking Number <br /> WASTE MANIFEST C OO`O 411-3 1 61,510-�b 3- Y3 b / 000257467 M W <br /> 5.Generators Name and Mailing Address Generators Site Address(d different then mailing address) <br /> q64B AL gRO IrAL. K4M � c-M(A/T LLC . 16LiG', A. A r <br /> sre to A), S-t O c 1,_-,V C) r.l, C 9 Seer <br /> Generators Phone: t d S <br /> 6.Trans r 1 Comps y Name U.S.EPA ID Number <br /> 7.Tans iter 2 Company Name U.S"TPA FD WmbeT <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> G LICA 1-' H.l4R-���RS <br /> ,'4500 14 Log= Ab <br /> rt tx1 i ca.d W f 4 -�16 <br /> (>4�T <br /> Fa s 7 '� ••�� <br /> ga 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(i(any)) No. Type Quantity Wt.N01. 13.Waste Codes <br /> 1. <br /> 4 3� <br /> Z 2. <br /> W <br /> 0 , <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Add' nal Inform3don <br /> N ,Zr-rL6=#= C l� Sa-I5 <br /> USE -0P-006,0- P*-ir;; <br /> 15 GENERATOR'SIOFFEROR'S CEtTIFICATtON: 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[abeled':rded,and a in all respecc-is in proper condition for transport accaraing to applicable internsUonal and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I oeNfy that the coolants of is consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I car*that the waste minimization s ment identified in 40 CFR 262.27(a)(ff I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratorslOfferoes Printed/Typed Name Signa Month Day Year <br /> n in <br /> 16.InlemationaiShipmerts <br /> ❑Import to U.S. ❑Export <br /> 6o n .S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransponerAckn wledgmenlof Receipt Maler ars <br /> Transpo 1 P intedrryped Name Signature nth Day Year <br /> QTransporW2 d Name S19mom Day Ye <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type Rejection ) <br /> L.�J Residue ❑Partial R'coon ❑Full Reaction <br /> Manifest Reference Number. <br /> 18b.Memate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facifilys Phone: <br /> W 18c.Signature of Alternate Facility(or Generafor) Month Day Year <br /> Q7 <br /> Z <br /> H19.Hazardous Waste Report Management Vlelhod Codes(Le,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C L 2. 3. 4. <br /> 20.Designated Facility Owner or OperatorCertification of receipt of hazardous materials ce vered by the manifest except as noted in Item 1 Be <br /> PrintedtTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF RF0.111RF4) <br />