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Please print or type. Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Eme ency Response Phone 4. t <br /> WASTE MANIFEST ,t err Ed 0 0 4 4 5 0 `� � ��{' �� —�3� I1 r tt �1s 9 � GBF <br /> — - - - S GetteratoYs Nam�tat anrd�,�Mya� illrrg Addtr�^e�s+s�A - <br /> WIRS <br /> EFT <br /> 360 KCK711aEY AVE <br /> Generator's Phone: 7 171 97 ,t 7 "Y q U;A 6 12 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> ERITAG �� 6uRY3T L C :jEAKr Lida', " L R 0 0 0 143 0 0 6 2 <br /> 7. Transporter Company Name U.S.fEPAAID�Nummbbe�r�yy� ����/ <br /> I ! , �l /� 'L� itt4lioY <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> xS 4 E STOREY FX <br /> 00JACGE1r A2 85225 CI - ? <br /> Fadlity's Phone: <br /> 67 <br /> 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 116T0101 12. Unit <br /> and Packing Group (if any)) 13. Waste Codes <br /> HM No. Type Quantity WtJV01. <br /> rod NttttD07.',�Ftt'•RA B'EGUATEDr WILY DEBRI . 13�'t713�iIMMI <br /> Z 2, <br /> W <br /> f.7 <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions andAdditional Information <br /> 2 ) CC " 423SA0 — fir TS4a 219167— 1 M4I <br /> c m( ted rets nW b� garksrbr trdltiNts eta y e hOrly Q11 iritflol 49mm iv tQ rvJd or sutili€kitip edditind irwiio ors ri7 gwrA*Kt° F bdsliff. <br /> 154 GENERATOR'S/OFFEROR'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 intemational 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 EPAAclmowledgment 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 /> Generatorsfftmes Pdntedrryped Name ( Signature Month Day Year <br /> c <br /> shipments 16, International <br /> ❑ 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, TransporterAcknowledgment of Receipt of Materials <br /> Uj <br /> Tra rte 1 Pitted/T Name Signature Month Day Year <br /> O <br /> a <br /> Apo rarter2Pdnte yped Name Signature Month Day Year <br /> p" i4ir, � <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity 1:1 Type ❑ Re ue ❑ Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 186. Altemate Facility (or Generator) U.S. EPA ID Number <br /> V <br /> LL Facility's Phone: <br /> W 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> z <br /> 19, Hazardous Waste Report Management Method Codes (is., codes for hazardous waste treatment, disposal, and recycling systems) <br /> LU <br /> 4. <br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifes x t as noted in 18a <br /> PMdName ti Sig .V Month Day Year <br /> P <br /> 0 <br /> I <br /> EPA 6700-22 (Rev. 12-17) Previous editions are obsolete. DES GNATED ;: a m ITY 0 EPA's e-MANIFEST SYSTEM <br />