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Please print or tvoe. IFarm designed for use on elite (12-nkldli ftewritar.) Form Approved. OMB No. 2050.0039 EPA Form 8700-22 (Rev. M- T Previous editions are P13k rte: DESIGNATED FACIDITY TO DESTINATIONN&STATTE (IF REQUIRED) UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number CAI-flOQd2�{g65 2 tlnitibr US.11nc 0 1 8 3 4 2 2 4 8 J J K WASTE MANIFEST 5. Generator's Name and MWIIn2 Addle s G.enarawes Sile Address (V different then mailing address) es zra IsaIJIM- jA ` sA4 m, Generator's Phone: 6. Transporter 1 Company Name U.S. EPA ID Number UNIVAR USA INC. CAD010925576 7, Transporter 2 Company Name U.B. EPA ID Number ENMUND EQCI EPNO-Mr CO. AZD982403586 8. Designated Facility Name and Site Address U.S. EPA ID Number US EC OLOGY BEATPY NVT330010000 PO BOX 578, 8WY 95(11 ILII S OF BEATPY);. BEATIY, NV. 89003-057 Facilltyrs Phone: (800) 239-3943 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.fvol. t NA3077. Hazankan wasic, solid, n o.s. aAmd), 9, PG III, DO0 (ER(3#=171 ) r �1 l O� 181 Z 2. LD J. 3. 4 14. Special Handling Instructions and Additional Information 1.070118303-13077(Lead and Acid Debris)~1 PLACARDS PROVIDED BY THE CARRIER 1PPERES O DRIVER SIGNATuPF- -019RANT ****FCALLER MUST IDEMIPY UNTVAR USAS (CONTRACT # 97569)0*0* 15. GENERATOR'SlOFFEROR'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, marked and labeled/placarded, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator'sOffercrs Printedrr ad Name Slgnalure Month Day Year 'Bk e. i q -J! W 6. tomallonal Shipments ❑ Import to U.S. ❑ Exportfrom S, Port of entry/exit: = Transporter signature (for experts only): Date leaving U.S.: LOC 17. Transporter Acknowledgment of Receipt of Materials G~CTra ortor 1 Printedfryped Name Signa Month Day Year CL �� o G Transporter 2 Printedf typed NameSI store Month Day Year r 1 C�77 LFy�•`F 18. Discrepancy 18a. Discrepancy Indication Space ❑ quantity, ❑ Type ❑ Residue j ❑ Full R j ❑Partial Reaction lecilon Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J_ U LL Facility's Phone: W 18s. Signalura of Altemate Facility (or Ganeralor) Month Day Year Q Z 19. HRzUFk1J$ Waste Report Management Method Codes (Le, codes for hazardous waste treatment, disposal, and recycling systems) G 1. j 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of mcelpl of hazardous materials covered by the manifest except as noted In It rinfedfTyped 17377 Signature f Day ear EPA Form 8700-22 (Rev. M- T Previous editions are P13k rte: DESIGNATED FACIDITY TO DESTINATIONN&STATTE (IF REQUIRED)