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Form Approved.OMB No.2050-0039 <br /> mus 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number SKS <br /> ntFEST CR�..�►_J3.342ivt.: `' r' VIAS <br /> -ator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> .-Last t_aner'8 & G Group Inc <br /> 16 E Roth Rd <br /> Generator's Phone: P 07-Sets-03C-13 <br /> 6. ns <br /> Traporter 1 Coma Name U.S.EPA ID Number <br /> A:=;. SYsTEAS INC rx;�,a aai �a <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ti-1 v;t?tU i AR.8LkB F_Nv `,alit. 1M., <br /> 8.Designated Facility Name and Site Address GLEAM HARBURS ENV 1 RLlhiMENTAL SLRV I CLG;j i ; U.S.EPA ID Number <br /> Z'a4'7 8 H i CdHWAY 71 <br /> W-2125-4 ZK I BF�i-t- E 69145 _ _ <br /> Facility's Phone: <br /> 9a. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM <br /> and Packing Group(if any)) No. Type Quantity Wt./Vol. 13.Waste Codes <br /> a. 1. ti a _F:is ri,.A II,TE FLrt ii$43LE i..IGUIDS, <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Information s 875575L'15 i:AEIbabw I.JI]II <br /> H EMER664CY#80a•-468-1Sty/T!`I-L intrac:t retained oy generator confers .a�encY author i'. <br /> pax% i.S'sS.r1 i, fi.^c'.t?'i� Or}�, Il0 ?t�f! t?Y`' $tt .1a�: ��:tl�.'� rrfC;1 p? ni t:tx �.3r �.F,.fs�:. 7tt E:Iwclf?ti-P ,0nI �! F� :f <br /> 15. GENERATOR'SIOFFEROR'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, <br /> 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_ <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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. <br /> Generator'slOfferor's Printed/Typed Name Signature Month Day Year <br /> J 16.International hi a is <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> I­ Transporter 1 Printed/Typed Name Signature f Month Day Year <br /> O <br /> z Transporter 2 Printedl Typed Name Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ ❑ ❑ ❑Full Rejection <br /> ❑ Quantity Type Residue Partial Rejection j <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q - <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />