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Please print or type. Form Approved.OMB No.2050-0039 <br /> a.Mad ra kir�p Ny(nb�jr F <br /> UNIFORM HAZARDOUS 1•GeneratorlpNurnber 2.Page 1;f 3.Emergency Resp -lm-��, � ��1 4 V 384 F L <br /> WASTE MANIFEST VV55(i..ilCCii BBB- ailing address) <br /> 5.Generatmys�lameaand Mailing Address Gigs Siia�d (j(„�(f�rentahn <br /> €;roLlk PKwy Suite 400 4620 S Hi 99 <br /> Johm Cheek.Grp 3( 7 Stock-- , 16 <br /> Generator's Phone: "0-232 6%7 U.S.EPA ID Number <br /> 6.Transporter 1 Co��mpp�..y..� me <br /> ADVr+rv�.tD C WMICAL TRANSPORT LLC <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Desi nand Facili a and to Ad ess <br /> g ^mmTyr ecycI �`ed &A DE C.V. <br /> ArxiSldor Veairt rU 390� isW1.%dorxio <br /> Ttjuarra, BC 2ZW <br /> Facility's Phone: 52(684)624-4455 <br /> 9b.U.S.DOT Description(including Proper Shi in Name,Hazard Class,ID Number, 10,Containers 11,Total 12,Unit 13.Waste Codes <br /> 9a. P f 9Shipping No. Type Quantity Wt.Nol. <br /> HM and Packing Group(if any)) r <br /> X 1, 0141,M3,waste F81FIArftatcbd M y OF 2,50 P <br /> z 2- LJM175,Waste solids"t&irtitt �ammal3le tigtld(t t�.ct.s. pF <br /> 352 p001 003 <br /> 0 X (Aceloae,TWuem),4.1,1'Csll <br /> 3. <br /> 4. <br /> 14.Special Handling"Instructions and Additional Information rVoItRAMENIM 'uxa sne rim <br /> 1)ERG#120, 80109 98#i <br /> 2)ERG W133, BOW 3iMM2 <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,ard are classified,packaged, <br /> marked and labeled/placarded,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 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 /> Generator's/Offerors Printed/Typed Name j Signature Month Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> ix 17.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> � <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> co lr/co <br /> Transporter 2 Printed/Typed Name Signature Month Day Yeeaarr <br /> ~ 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> J U.S.EPA ID Number <br /> U <br /> u Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> Q Month Day Year <br /> z <br /> N19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � 1. 2 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certificalion of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name <br /> Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COP) <br />