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Ple$Se print or typeForm Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.Generate,ID Number 2Page l of 9.Emergency Response Phone 4.Manifest Tacking r <br /> WASTE MANIFEST ,4 - <br /> ME <br /> l .5i :N`7 33 f FLE <br /> 5_Gonanro&Name and Molina AJtlress German ofs Site Address(if different than malling atltlress) <br /> Genearola PM1onb: <br /> 6.Transporter 1 Company Name US.EPAID Number <br /> Ir r <br /> 7 Transporter 2 Company Name US EPA IDNunbor <br /> 8.Oeregnated FaOlity Name add$its Address US EPA IO Number <br /> Clean 04arbme:Env irrninal t'al ServimIt Inc NE:D 991 : 2 ;1513 <br /> 2247 Sat!{ f HlC11waY 71 <br /> Fa%arh>)dld�Olod:NF F9145 <br /> 4909A P'llil <br /> 9,- 96.US.DOT Dasceptlon(Indoding Pmper Snipping Name,Hamid Cass,IO Nonose 10.Containers 11 Typed 12.Ung 13.did,Codes <br /> HM and adding Group(,[a,)) No. Type Coal St coal <br /> a .!taO,WA,IC ACRDS01s,E'LAM MAf;I C.IF AT PIOI' DOS D(10 Ott <br /> � x LDING 11 , APAC.ITY) .1 OU3 CF 80030 P �— <br /> 0001 :) i 34:: <br /> z <br /> 'mWASTE MEDICINE.110U16.FLAMMABLE.TOXIC, PHRM C1002C1002 11010 <br /> % <br /> � x _ 3,(0.11,P011 029 CF 00300 P _ _..: <br /> 01/39 Sal 34:' <br /> 6 <br /> vI:IA,WASIE MFDICINF,SOLID.10%ti',N O.S., PHRM P001 3:L[ <br /> x <br /> ARiNI.G.i,17G 11 001 f;F 00009 P <br /> ' 52 <br /> 4 <br /> NCRA HAZARDOUS WASTE.LIQUID%(FORMALIN. 3.11 ,34kE <br /> Nr) h0i CF 00000 IN <br /> 14.Special Handling Instructions and Additional Information MEXIS728 NCT MX"T Ji' VDIsla 4 <br /> 1 rHl708003 FRGN126 1320,2Y70 men, LINK 3 I8 less TRAN i Dump <br /> 2 .C11101371VRAT130 FRGN1.91. 4.3920,15310 <br /> A CH12i2915 ERr illi 7:310 <br /> in main to 1 <br /> .1 r 1.1113 p11 <br /> _ 7r3C LIPfID40l4PDP19fDf P]I11Wfial 1. <br /> 16. GENERATOMSIOFFEROR'S CERTIFICATION; IM1ereby tleder6 Nat Ne contents Of lM1is conslanm¢n1 o finly antl accuately tlesCdbetl above by the pmpereM1lpp nA nemr- era at, <br /> paskeged <br /> marked and labeledlplacarded and as In all remarks in poster condition for porter according to appll<able Imanatlonaland national goveormentel regulations_Ifexton shipment and I em the Primary <br /> Eryoner,I covered,that Ne contends of this summa, rant contain to Ne forms of the attached EPAAc nowledgmenr of Consent <br /> I cenitythat the waste minimization statement identified In 40 CFR 26227(a)(if I am a Targe queniry ganeatDU or(b)to am a small results generator)Is true. <br /> GandmolacrOflemr's Prinieroffmad Name ,. _ \ SignaWre _ Month Day Year <br /> .lntemafienal SM1ipmenls Ira❑ M1b U.S. <br /> f i6W ❑Evpon from U.S. Poe ofeniUS <br /> ? Tanstotlersignature(for exPons only): Dale laaving LLS'. <br /> W 17.Transponer Acknowledgment of Receipt of Materials <br /> Transponer l Printedyllied Name Signature �,� Month Day Year <br /> it, U111100 KE14 <br /> Themponer 2 concept Name Signature Monty Day Year <br /> W Derogatory <br /> 1Be.DlecrepanaylndmaPan Spare ❑ Debtor, El Type ❑Residue f❑Panel Reeefmn [:1 Full Rejedlon <br /> Manilead Reference Number: <br /> r My,Alternate Facility for Generates) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility PhoOa. <br /> Noe 16c Signature ofAUi Facility(a Generator) Monty Day Year <br /> se <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(IA,access for receptors wash tomanent,diposal,and leasing systems) <br /> 0 1 11141 2' !t040 5. 11040 4' H040 <br /> 20_Designated Fabry Owner or Operator:Carlinted of receipt of hamrdons materiels covered by the manifest except as need In Item ge <br /> PrinledlTyPed Name Signature kal Day Year <br /> EPA Fmrm 870U 22 Rev.1,2217) Previous editions are obsolete GENERATOR'S INITIAL COPY <br /> r _ _ 'Vis._ 6121032177274102 V'PW <br />