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Generator acknoWedges that no maleft change has occurred either in tha cheracleristics or in the pwass ganeratklg the material. <br /> Please print or type. Form Approved.0MB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 GepetaI Dllu61§ 2. age 1 of 3. e r s n Ptrgng �4.lil!56s�TraykiSywn1OWASTE MANIFEST AA LL UU fV1 18 ( b 66 F L E <br /> 5,fjNflPWF6g Address Generators Site Address lit different than mailing address) <br /> 10664 TdnkvPk%W MME <br /> Generators Phone: <br /> W18 <br /> fi.Transpo ter 1 Company Name U.S.EPA ID Number <br /> ars. <br /> Cita}lwbEmiromrl#ntalServlces,Ina IYIA;Q013 3�< ?rGp <br /> 7.Transporter 2 Company Name U S.EPA ID Number <br /> a designated Facility Name and Site Address U$,EPA ID Number <br /> n H wbors AMSorlifte LLC <br /> 1 600 NorthAptus Road ihT�' 5,5'2'37:7 s <br /> Grua;fJT +�D�9'• . <br /> Facility's Phone: � � ' <br /> ga- 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.unit <br /> [iM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity N1tNol. <br /> ix— <br /> 1. _ <br /> 0 x <br /> 0A1, D Fic 14 . <br /> LU <br /> LU <br /> 2 r WAISIEG)ODIZING SOLID' r D 0i0 , A <br /> x r PbTA5SiUMPERMANQ"n5AX&W 601.. D'V. <br /> OEot� <br /> P.:.;. <br /> U 5095 <br /> 3.U21M,VW11 1110M <br /> r r ' 00f CF 0005 : 4., <br /> U(114 Ute 13!'.. <br /> RECYCLE) 0 01 C F. 00020 <br /> 1 IjIxlstnrctldns and k. <br /> 2..IS-OZ-s <br /> 3.$S-ibkii. <br /> Cvglitact rMaki ed <br /> von Inial transaorter 10 Wd or Y [orders agent <br /> Itis• ern aerwrator!5 6e�raNiir giroo6�i.pLiWort. lnE ,#sate <br /> 15. GENERATORVOFFEROR'S CERTIFICATION:I hereby declare that the oonterds of this consignment are fully and accurately described above by the proper shipping name,ani are classlfted,packaged, <br /> marked and labeledlplacarded,and are in all res"'m proper condition for transport according to applicable international and national governmental regulations.if export shipmenl and I am the Primary <br /> Exporter,I cerldy that the contents of this consignmem conform to the forms of the attached EPAAcknowledgment of Consent. <br /> I cediry that the waste minimization statement ideri feed in 40 CFR 262-27(a)(if I am a large quantity generalor)or(b)(ifi am a small quantity generator)'a true. <br /> GeneraloeslOfleror's PrintedlTyped NT Signature Month pay Year <br /> 16 International Shipments <br /> r ❑Import to U S- ❑Export from U.S. Port of enlrylexit: <br /> ? Transporter signature(far exports only): pale leaving U.S.: <br /> AZ LU <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> a Trans crier 1 PrintedlTyped Name Signature Month pay Year <br /> a F.t CATML 07 is ..20, <br /> Z Transporter 2 PrirdedlTyped Name Signature Month pay Year <br /> 4 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> N 18b.Ahe mate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: <br /> LL, 18c.Signature of Allernale Facility(crGerreratar) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Me Mod Codes(i-c., <br /> codes for hazardous waste treatment,disposal•and recycling sywems) <br /> Q1 2' r'. H141 �,75r40 THO-40T <br /> H141,- <br /> 20 Designated Facility Owner or Gil rater Cerlificau'on of receipt of hazardous materials covered by the merriest except as nclk in Item 18a <br /> Prime d N me a re Month pay Year <br /> EPA Form 8100-22{Hev.12.17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />