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Plea .e print or type. (Form dQsigned for use on elite (12-p*0 typewriter. <br />edit <br />- <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone • <br />2Appe rov. 0.2050-0039 <br />/. Manifest Tracking Number <br />' <br />WASTE MANIFEST I C A L 0 (f 0 2 6$ 3 7 j <br />VAX) 4,...A �93 0) 0-filviiii .. <br />3 JJ <br />S. Genemlofs Name and Mailing Address �v Generatofs Site Address (if different than mailing address) <br />lCH.NMIA- AkJf00ISMANTLER13 p•- PICK NlPIMA AL) k)LNSMANiiikE , <br />N0,60 0301-0 CV -N I EIC DR. STE 320 3%6` CLARK J)RJVV <br />ft%k'H0(J-C?tDMA GA :;5f10 61OCK10N CA ta520S <br />GerstellPhone: k3 1 6 'r - ) <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />:? 1001,1VV k P4ViIi0NMEt4TAL SERVICES INC; TRANS <br />;; A ii 0 0 0 1 7 1 t) 1 7 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />,I�.' 7idVRONML,NIAI_ IN1IzRNAJ'"y)AI. :": A Ir. 0 Cr 0 1 <br />S. Designated Facility Name and Site Address U.S. EPA ID Number <br />i. -a. 1;A7+i I-IA?iF C)i , F'L D0RAD0 <br />eOs4 APAEM AA" (-*NCi, - <br />'.; f-x)RALXJ AR 117:30 <br />Facilit Is Phone: R70 (,4. 'SCv77 A R D 0 6 9 7 4 f3 1 c) R, <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, <br />10. Containers <br />it. Total <br />12. Ung <br />HM <br />and Packing Group (8 any)) <br />Quantity <br />Wl.Nol. <br />13. Waste Codes <br />IN <br />Type <br />w ,��fli If I AMMAN. E LIQUIDS, N 0 S (GA$01-1141 <br />1 PI <br />r <br />w <br />w <br />2 i rr.3 VN3 V0,64F F1,AMMA8111 I.IQUIDS, N_C.,'i (C;1430L?NE"0L)1 <br />0 <br />1'INSAIF) <br />- <br />L3p'ila <br />3d:, <br />! <br />if <br />3. <br />4. <br />14 Special Handling Instruchana and Additional Information j FliariNTIFa1>IQ L'r <br />a:oNtw F??r1 1?g ERC l#17L <br />;.1a:Iiau:1:,L,. 1O�fn t'It,4u4ur,aNcr,;,;ly,�yl. <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 Iabeledlpiacarded, 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 lens of the attached EPA Acknowledgment of Consent <br />I cemy that the waste minimlufion statement Identified in 40 CFR 261 (d I am a large quantity generator) or (b) (111 am a small quantity generator) is true. <br />GeneratoesrOgeror's Printedrryped Name Signature Month Day Year <br />IS. International Shipments <br />Import to U.S. 1:1 Export from U.S. Pod <br />n❑ <br />of entry/exit: <br />Transporter signature(for exports only): Dale leaving U.S.: <br />w <br />17. Transporter Acknowledgmentof Recelptof Materials <br />OTransporter1 <br />Prinlewlyped Name. Signature. <br />_ .;^' Month Day Year <br />a <br />w <br />X try ..- <br />Z <br />< <br />Transporter Printecirryped Name Signature Month Day Year <br />H <br />} <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity Ll Type ❑Residue ❑PaNal RejecOon ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />V <br />nai <br />Facility's Phone: <br />18c. Signature of Nternate Facility(or Generator) <br />Q <br />, Month Day Year <br />Z <br />H19, <br />Hazardous Waste Report Management Medmd Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />p <br />1. 2. 3. 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazi*dous materials covered by the manifest except as noted in Item 18a <br />PrimedlryPed Name Signature Month Day Year <br />Fps <br />Form 8700-22 'Rev3-051 P ' b <br />revlous Ilonsareo so a,.. GENERATOR'S, 11NATIAf_ <br />