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Plept1wint Or typo Form Approved. OMB No. 2050-0039 GENERATOR UNIFORM HAZARDOUS WASTE MANIFEST 1. Generator ID Number C 14194i g I L(56)61 14 0 2. Page 1 of ) 3. Emergency Response Phone (g00.) Sql -(4(1/2 1 4. Manifest Tracking Number 0 0 713 8 6 0 4 GBF Generator's Name aid Malting Address Generator's Site Adinass (i1diffort than mpiling address) 13,AiS c PcAl Way 4) S F Ra l I ttj6t Dio.mtmcl 4 Ewer 43, Si '7LIO Ca Ota ' y vi ic.. it64 .. c 0 .fi '2(A6 - SlOck 4-04, 04 al 520S A 6..re .o Genc4r1A-95e( -Z66. 24 I 4c Iran .mars 1 Company Name U.S. EPA ID Number , C i ( 0 Y1 61 evtia 1 Se‘ru r(eS 1. i t IC I C )4 g000d3cil (1 7 . .-h Tianspoeor 2 Company Name -- V I VVII r\fl Va l U.S. EPA ID Number CICIa.111.jk-1 ( . I (W-u-50?-1-1c1 7- .)-16.7 isa., FA 8. Designated Facility Name and Site Address Ai& k- -T-S 0 C TAX., vJ moo-fe i4t...1 '44370:4 1(j 1-C.I. CO 923 lb (969) 7g - 111 (II U.S. EPA ID Number C14 o ci 22 LA/Li 0 fl Ga. 9b. U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes ilm and Packing Group di any)) No. Type Quantity WI.Nol. 1. VW 42(934 4-16Q04tict6 Wc4S-4-e. , I u 0 331 - (6114 Wal-e,,) 01 DM &j 6 -- 2. Abu avA -tc,k20,r(k)us Wa s 4-e 1 sotia 3S2, (6 il Wi-/ 4bs -, ihmt) 01 'DM 106 9 3 4 _ Special Handling Instructions and Additional Information -30 ig (170 (42_ 1 6 IX ..e.Z;DM 2,. ht 55061 (J SER:4A6042. WO4V)1q11?)0 wa-,i, it ct B1) zzl a-awl Pa,c;42.* clot) 72122co2. GENERATOR'SIOFFEROR'S CERTIFICATION: thereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, arid 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 Exporter, I certify thal the contents of Ihi consignment conform to the terms of the attached EPA Acinowledgment of Consent. I car , .• . asle mini li.n s ement identified in 40 CFR 262.27(a) (if I am a lorry quantity generator) or (b) (ill am a small quantity generator) is true. 1 ...x.,,r, t, Signature Month Day Year GNIFt s: .1 . .4 Rel j -k fre 2-) OF , i 4 i-3-- I ) I I 2-; r-- F_ 1 6. International Shipments LI Import to U.S. L Export from U.S. Port of entrylexit: Transporter signature (for exports only) Date leaving U.S.: ir L.L.i 17. Transporter Acknowledgment of Receipt of Materials TRANSPORT. Transporter 1 Printed/Typed Name Srgnature Month Day Year I i I ZS 1 23 Ft •porter 2 Pri e \T pt Name \ Month Day Year 12;5 I 23 ) -4- DESIGNATED FACILITY 18 DE. -moan cy _ Discrepancy Indication Space LI Quantity LI Type FIResi, e [ .1 Petal Rejection Full Rejection Manifest Reference Number: Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I -1Bc. Signature of Alternate Facility (or Generator) Month Day Year I I 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) I . 2. \..,.\ \ 1.1 li 3. 4. 20. Designated Facility Owner or Operator: Certnica ion of receipt of hazardous materials covered by the manifest except as nctc• In Its 18a Po (Typo( we Signalui - Month Day .1 / .•.• k-I\11(C\ n6 I r i fi i2 PI Yeas 23 EPA Fomi 8/00-22(Rev. 12-17) Previous editions are obsolete. DESIG ED FACILITY TO EPA's e-MANIFEST SYSTEM