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Please print or tune ;--- (!"'T! EPA Form 8700-22 (Rev.; 12.17) Previous editions are obsolete. ! DESIGNATED FACILITYTO GENERATOR UNIFORM HAZARDOUS 1, Generator ID Number 'CfClLwt�u�0;.,tii:'1 :ID 2. Pag 1 of e{ 3. Emergency Response Phpa:e /n 4. Manifest Tracking Number WASTE MANIFEST ] 9t"; 6 2KS 5 Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) - :.1..: i .:. ld L C1D.i Generators Phone: "1) D j3 69216 6. T ai rAle�J omer' U.S. EPA ID Number _ SYSTEMS IN:., TXR0000k 1211 7. Transporter 2 Company Name U.S. EPA ID Number CLEAN HARBORS EAV 'SK IML. S• Designated Facility Name and Site Address CLEAN HARBORS GRASSY ir(UUNTA IN U.S. EPA ID Number 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT ;'., tai=l= I ---8th FiP!f�t_!_S , UT 84@83_ 435-884-•8915 Facility's Phone: ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes Na. Type HM and Packing Group if an 9 p {� Y)) Quantity ty WUVoI. 11 NON RCRA HAZARDOUS WASTE SOLIDS, t. h P o i AgSORBE NT S CONTAMINATED WITH OIL.) , +;i- z 2. L 3, 4, 14. Special Handling Instructions and Additional Information f36 1962 11 LJ`17+C r:'_4FI Ch7L�f2�iE[+ICY#5�[r �kbEs�1i13 �GH/Sk1"CF"I- ar�tr ct retained by gent too, confers a einCy atathori-- on 1r1it i a.. P1sC1 rte i0 a ` 1i I r' 1u 1 -i • - n r- ,f f 15. GENERATOR'S10FFEROR'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 labelediplacarded, and are in all respects in proper condition for transport according to applicable international and national'governmentai 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 I certify that the waste minimization statement identified in 40 GFR 262.27(a) (if I am a large quantity generator) or (b) (if! generator) is true. Generat�orrsslllOifi Printedrryped Name Signature Mdrth Day Year -J 16: International Shipments Import to U.S. -1Expart from U.S. Por} of entrylexit: 1. -Export ?1 Transporter signature (for exports only): Date leaving U.S.. W 17, Transporter Acknowledgment of Receipt of Materials a TranBWrfer 1 ?rintedlfypetJ-1lante Signature Month Day Year R I� / 2 Transporter 2 Pr tedlTyped Name Signature i/ Month Day Year �i r t v V E�"' E7 2 18. Escrepancy 18a. Di6crepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Faciiity (or Generator) U.S. EPA ID Number _ U cat Facility's Phone: Jul 18c. Signature of Altemate Facility (or Generator) Month Day Year t- d z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1. 2.3. 4. -Y/?L 20. Designated Fadlity Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature = Monti Day Year EPA Form 8700-22 (Rev.; 12.17) Previous editions are obsolete. ! DESIGNATED FACILITYTO GENERATOR