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Please print or type. GENERATOR ÷ I UNIFORM HAZARDOUS
<br />WASTE MANIFEST.
<br />1. Generator ID Number
<br />CAC003 I 69 710
<br />2. Page 1 of
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<br />3. Emergency Response Phone
<br />800-899- 44 2
<br />4. Manifest Tracking Number
<br />0 0 6 8 2 0 4 2 3 GBF
<br />S. Generators Name
<br />1 1-y1041
<br />Generalk9PKone:
<br />otaAlAnneir
<br />and Mailing Arros, Generators Site Add on ()different than r.nallingiaddress) , il'It . it;tude fude (A56(.1 37.63537s, -'0s P(ace C.A;fe 44 S---S0 y ONAMASG rig, - I li.11,14 2g) alCcAvyy , f , cts23 1 16 cr I- ti-so I ,
<br />Ti:\.agei 1 Cornpany Name U.S. EPA ID Number
<br />C, EYWifOrnevrteA( Se,yvic -,es, .1-11e, I c-AR 00003011i+ .
<br />Transporter 2 ID Company Name U.S. EPA Number
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<br />Designated Facility Name rnorle
<br />ot-,Alev
<br />Address ack U.S. EPA ID Number
<br />S Ecoto3y
<br />ii mi lessgm4iDfl3e2A-tty 6 80,1411Y1 AN) g C100.3,
<br />Facility's Phone:. ga)- 23cf - r5qi-k5-- 1 Nv T -3010 1 0 00 0
<br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit
<br />Elm and Packing Group (if any)) No, Type Quantity Wt.Nol. 13. Waste Codes
<br />v 1" U 1 \) II- 5 Acihe_SIveS 1: C,GAtc441 i./ CA, f teittivvude 1 D:01 331
<br />0 DM 3 G-1
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<br />CAOVitt(inlficirwi ctUe - cy4zci ) hes;ves, 11-. I ) p(-1 I 1 DM too P
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<br />14. Special Handling Instructions and Additional Information
<br />. ai 17bii.8 I '
<br />p.04.171431-anciiie2 -02-1-;(,Da
<br />I.) 01 )(DIM . 0703)8451-0
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<br />23(9)( OIX.1)10 070 12_ 300-'17327
<br />15 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/plac,arded, 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 Conseni
<br />i.certify that the waste minimization statement i entiVlin:10 CFR 262.27(a) (if lam a lase quantity generator) or (b) (ill am a small quantity generator) is true.
<br />...OxlyscarpidrOtza2011 arne _ k, v_a_ii,....7.4 Sig .0 • Month Day Year
<br />---"'i-----;--,P_ 'A, .e..L.,- c..... Jr Ill I.2C12- _, r- 16. International Shipments Import to US. Export In . . Por-slsr-if-criby exit:
<br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials
<br />Transporter 1 Printed/Typed Name Sign Month , Day Year
<br />4.----- rs,
<br />\ CDC- \ 4 104 1 i 9.:1262z. --:-C7S--•L• PAt • es, e>-
<br />Transporter 2 Printe yped Name Si. • .ture M9ritti Day Year
<br />' I _ - -74 DESIGNATED FACILITY 18. Discrepancy
<br />Discrepancy Indication Space Quantity Type
<br />updcfieri wlirri rere,trigiSIDC
<br />Residue Partial Rejection Full Rejection
<br />_ .).. Manifest Reference Number: S-sll'i--
<br />Alternate Facilit•Aor Generator) U.S. EPA ID Number
<br />Facility's Phone: I
<br />Signature of Alternate Facility (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)J4)
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<br />1 2.
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<br />1/3 )-
<br />3. 4.
<br />20. De ignated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted In Item 18a
<br />-
<br />P ' /Typed Nam Sig ture Month Day Year
<br />Lociel 1 I Si lo I
<br />Form Approved. OMB No. 2050-0039
<br />EPA FormForm 8700-2 ) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM
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