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rit r <br /> Form Approved. OMB No. 2050-0039 4 GENERATOR . . UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />C AL WO S5G772,4 <br />2. Page 1 of <br />l <br />3. Emergency Response Phone <br />6CV. &LH. it Tt/ <br />4. Manifest Tracking Number <br />0 1 62 4 4 336 JJK <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />VIC HP Citle*:1C42. ° °'..- Vi o4L's 4 i 3 (0 GI <br />NI 5- to, LAI 1 7000 4Z i• D <br />„1-k- ,u0 i •-„, ioCI -3f) . KETTLE_TiA*4.) l_#(1.3 E <br />Generator's Phone: 1-Le7-- 7D5 • -/Uttl I LoCe k CP,- ciLc 2LID 1 <br />7 <br />nsporter 1 Company Name J.S. EPA ID Number <br />A-1-1-1(n"" S'%& ICAo6C386,42 -7q,1 <br />...n.,i)tank_jtvki.1-1-Pri-- <br />. Transporter 2 Company Name U.S. EPA ID Number <br />I <br />i.f CI, <br />Facil <br />8 Designated <br />halo <br />Facility Name and Site Address U.S. EPA ID Number <br />r146 E - Cki SPA 1_. ct,e 41,..) <br />E. Alit-IDP'41E- Lk' •07 <br />alot Q.- t" eoi c 'q i 3 I C A ‘4ze)2_59 Co <br />ga. 9b. U.S DOT Descnption (Including Proper Shipping Name, Hazard Class, ID Number, to. Containers 11. Total 12. Unit 13, Waste Codes <br />HM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br />1 11/4/W t-1.4 il ta it(24)0 V eS (A) A5 re_ , SO Li 1, <br />C__DSciasoor /WC> DEJSE-IS Wa-H- 1-• 54 H V PF-11111-1 t-- t" Li Ll Dikl g3cx) F <br />"SSZ— <br />2. <br />3. <br />4 <br />14. Special Handling I structionLand Addiaogal Informaticn_ <br />I -4\b- fev4R---7"- Orr2.322--3 \ -45' ' <br />3013t (W -22-- (x)2-32- <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 aH respects in proper condition for transport according to applicable intemabonal and national governmental regulations. If export shipment and I am the Pnmary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity gener(ee' rtt7'tTTi a small quantity generator) is true. <br />s/Offeror's Pnnted/Typed Name gnature Month Day Year <br />6e4gr i frg, 41/' Oiti AC/AVCI i2e60Jegf430e 18 12312 Z. <br />—I <br />I- <br />F- <br />i6. International Shipments <br />Import to U.S. E Export from S. Port of entry/exit _ _ <br />Transporter signature (for exports only) Date leaving U.S. TRANSPORTER' Transporter Acknowledgment of Receipt of Materials <br />T er Month Day Year 1 Printed/Typed Name ature ecar 76 <br />EA— (aim I -"'- --. la 110 <br />Transporter 2 Printed/Typed Name Si re r,/-• MiAth Day Year <br />A.tdr 1 -4-/i(2.---' 1"----- I -401) I:19 I 7Z DESIGNATED FACILITY I Discrepancy <br />18a. Discrepancy Indication Space Quantity Type E Res:due Partial Rejection Full Rejection <br />Manifest Reference Number <br />111h Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />18c Signature of Alternate Facihty (or Generator) Month Day Year <br />I I <br />19 Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1 <br />Hi ll/ <br />2. <br />20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br />Pnnted/Typed Name Signatur Month Day Year <br />Ird fel/ j —e's4,4k.;e2s- 1 .....,A// log I Zilli__ <br />EPA Form 8700-22 (Rev. -05) Previous editions are obsolete IGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)