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Please print or type.(Farm designed for use on elite(12-pitch)typewrite4)p 1--."q?77 �1_nt?1 - Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 011848919 F L E <br /> 5 Generators Name and Mailir4A - trBrent than mading address) <br /> Nlco hair'. H-:rrc� `Naim: Tro.t;nont�13r-t <br /> I+;OA119aic,,Roos eeR�t <br /> .Transporter 1 C&ffWyNaMCPr U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U S EPA ID Number <br /> XE D ,eoex At 6 4)P('?rX 3 rj 5j1r-' <br /> IT Designated Facility Name and Site Address U.S.EPA ID Number <br /> teen H;wborsGI-asSY Mountain LL%-- <br /> Miloc P—t-7 hAil— tu—, lk F V- i:-- ti t Lr 5 7 1 J V I Y D <br /> 17ad"%Wle. UT S40.29 <br /> ga, 91b.U.S.DOT Descnp'o a obi ng Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Parking Group(A any)) No. Type Ouantty Wt./Vol, <br /> 1 <br /> a NON-KRA HAZARDOUS WASTE,LIQUIDS.(OF.SEL,WATERT TP <br /> r <br /> LU z' <br /> -r--- <br /> 3. <br /> i <br /> 14.Special Handling Instructions and Additionat Information <br /> �� <br /> 1 r'Atn5n74.5 <br /> X- <br /> ;K 7Rk WbRidilbiNkAgift0oNii f Reritly 4edare U6 J cb'iiWVW& i Iej acid %q;a*odp"wwanr3 pa*aged, <br /> marked and labekdiplacarded,and are in all respects in proper oondbon 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 EPAAoknowledgment of Consent. <br /> I certify that the waste minimization statement identfied in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is he. <br /> roes Pntedy9na ea <br /> nerato INJJ�" 0" nth <br /> it v. r S <br /> -j 15.International Shipments <br /> F ❑Import to U.S. El Export from U.S. Port of entrylexit: <br /> = <br /> Transporter signature for exports ori Dale leaving U.S.: <br /> nY 17.Transporter Acknowledgment of Receipt of Materials <br /> w n Year <br /> II- T porter 1 Printedli a Name gnature Y <br /> ZT) f <br /> z Transporter 2 Pnnte ped Name n ay ear <br /> 18.Discrepancy le <br /> 18a.Discrepancy Indication Space ❑ Quantity T�Pe ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number' <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facil s Phone: <br /> w 1 Bc.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj <br /> H•1^' <br /> 20.Designated acil ry Owner Operator Certification of receipt of hazardous materials covered by the manifest except as in Item 18a <br /> S' at WREQUI <br /> EPA 8700 h NA <br /> ev.3-05) Previous editions are obsolete. D FACILITY TO DESTINATION STATE II <br /> 'ler,n aprhr.,. `it rho ar•nr i ztp narM04 fnr Anil Wit i arrant ttlp 6�;gata ria aanpratn;ie chinning <br />