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� we��s IIIIIiIIIIIIIIIIIIIIIfIIINiIIIIIfIIIIIINIIUIIIII�IIINIIIIIIIiIfN <br /> Please print or type,(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> 1 Ge Nxator ID Number 2.Page 1 of 3.Emergency Response Phone 4.111111111 <br /> UNIFORM HAZARDOUS ICAL000018659 c (800)326-1221 <br /> MnO 41 WAS <br /> WASTE MANIFEST <br /> 5 M(SreP lQ83'M�ORP. / DAWN JESS e" er - -I C'L'"F <br /> 3333 BEVERLY ROAD 2180 E. MARIPOSA RD. <br /> HOFFMAN ESTATES IL 69179 STOCRTON CA 95205 <br /> (209)48-8205 GEN: 11782 <br /> Generator's Phone: <br /> ranspongr I Company Name U S.EPA IONumber <br /> HERITAGE TRANSPORT, LLC / SIGNAL HILI_ IND058484114 <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> Eli , NTAL SERVICES LLC US.EPA ID Number <br /> 284 E STOREY RD AZD081705402 <br /> COOLIDGE, AZ 8528 <br /> (520)72,3-4167 <br /> Facility's Phone. <br /> ga 9b U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Conuav (a 11.total 12 Unk 13.Waste Codes <br /> HM and Paclong Group(t any)) No. Type cluanely, wuvoi. <br /> oc X ' RQ UN 1950,WASTE AEROSOLS,2. 1, (DO01 D(139), 331;D001 'D035 <br /> ERG#116 i C- 36 P �39� <br /> W <br /> X 3. RQ,UN1993 WASTE FLAMMABLE LIQUIDS, N.O.S. , D601; <br /> 3,PGII, (PAIN), (DOi)l),ERG#128 <br /> l 1 G122— }./ <br /> i <br /> X 4 RQ UN3139 WASTE OXIDIZING LIQUID, N.O.S., 141iD001 <br /> 5. 1 RII (HYbROGEN PEROXIDE ' 10-4:SODIUM — — — --- <br /> HYPI�CHLO� I TE), (Dl)01),ERG#14th 2 <br /> 1Isoec'Il 5 2-5apd,Aodilipgal ��atio�yr -vii 3.W12 0450303_LDR 4.W9 0439579 LDR <br /> 4W�GO ) LL1h( L 6 . NF1AZvi ► O,Ki-L, <br /> v.' 3. 3 -1 I X C Lj 181 X'Z [12644057 G <br /> 15. GENERATOR'SIOFFERORS CERTIFICATION: I hereby declare that the contents of his consignment are fully and accurately described above by"proper shipping name,and are classified,packaged. <br /> marked and labeledlplacarded.and arem all respects in proper condition for transport according to applicable irlemabonal and national gommmental regulations.If export shipment and I am the Primary <br /> Exporter.I certlly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I cai that the waste minimization statement denntififie�dd in 40 CFR 262 27(a)(d 1 am a large quar>tiry ior)of(b) if I am a n qu razor)is true. <br /> 9t <br /> TO � �`-'1� 0 oro y <br /> 16.Intemarijbiral Shipments ❑Import M U.S Export ho+n U S 1 entry exit <br /> = <br /> Transporter signature for exports Dale eaving U.S.. <br /> 17.Transporter Ackramedgment of Receipt of Materials <br /> � ransporter 1 PnrifedrTyped Name rgnature on Year <br /> g � � r o <br /> Transporter 2 ntedfTyped Name �grature ay ear <br /> 18 Discrepancy <br /> 18a,Discrepancy Indication Space n O„anuly ❑Type ❑Residue ❑Partial Rejection ❑Fut Reject on <br /> Man,fest Reference Number: <br /> 18b Allerrale raday or Generatx) U.S.EPA ID Number <br /> 7 <br /> U <br /> Q <br /> s+- Faul s Ptwne: <br /> W18c.Signature of Allemate Faddy(o(Cenerwor) Mnth Day Year <br /> a <br /> z <br /> H <br /> 19.Hazardous Waste Report Maragement Method Codes(i e.codes for hazardous waste treatment,disposal and recycling systems) <br /> ' H141 2 _�F�4} 3 H141 a. H141 <br /> 20,Designated Factty Owner or Operator Certficabon of receipt or hazardous materials covered by the manifest except as noted in nem 18a <br /> not yped Name Month Day Year <br /> '7 � 'D-A I I <br /> EPA Form 8700-22(Rev 3-05) Previous editions are obsolete IGNATED FACILITY TO DES NATION STATE(IF REQUIREC) <br />