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07-02—'11 08:02 FROM—KING ISLAND RESORT 1-209-951-9181 T-970 P0002/0003 F-716 <br /> • <br /> Please print or type.(Form designed for use on elite(12-pitch typewriter.) <br /> 7.Generator ID Number Form Approved.OMB No.20%0039 <br /> UNIFORM HAZARDOUS 2.Page l or 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTEMANIFEST .J ),.., �., ��� <br /> S.Generator's Name and Mailing Address - <br /> Generalors one Address in dapthenl than mailing address) <br /> "9Gs4tVtt F;ti:c3i nfD_E: t;1t,•.l'� <br /> Genera ku's Phono: <br /> 6.Transponer 1 Company Name U.S.EPA ID Number <br /> IF;t.N1! Iwv1 1bd 1,4i 1-1'flrU ?111 s ' iti'di. t1t%11'Jr; <br /> 7.Transporter 2 Company theme U.S.EPA ID4C Number <br /> r•i :. i �;� .: y. - ::'ij,:5,' " itl ..• Y..r' i {'i � =, it ' <br /> 8.Designated Facility Name and Sge Address 't <br /> t.;I I AIN 7J:13iiSi:S4}., U.S.EPA ID Number <br /> 1f);l.) I-,4I'ili(�'tf:::JS11 flGa11U <br /> Fap1iiys Phone: � <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Paddng Group(irony)) 11.Total 12.Unit 13.Waste Codes <br /> I <br /> No. Type Quantity WLNd. <br /> p ra(,)L rt;r r%1)•' (Int„ipilleri. (SfJ;1;�1: I} „ ,j fi111k,q <br /> Q t` .i I'r 1. - <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:Ihereby declare that the contents of this consignment are fully and are rarely described above by ther•�' r t • name,Ord are <br /> classified. <br /> la i •” <br /> marked and labeled/placarded,and are in all respects in proper ondidn <br /> onfor transport according to applicable International and national govemanlal regulations.Ilexport shipment and am the Primaryd <br /> Exporter,I certify that the contents of this consignment conform t¢the terms of the attached EPAAcknot-lodgment or Consent. <br /> I cndify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity gem elor)is two. <br /> G,rreretoyslOgeror's PdnledlTyped Name Signature r,7 - , Month Day Year <br /> V16.IntemationalShIpmentsational Shipmentsf �LJ Import to U S. ❑ExpoA from U.S ! Pod le ving U.S.der sgnalure(for exports only): Dal¢leaving U.S.:poderAcknowiedgment of Receipt of Materials <br /> er 1 PrinlpdJTyped Name, -.p SynalureMonth Day Year <br /> er 2 Prinfed7Typed Name Signature Manh Day Yearpancycin ncYintlroan Space Quantity Type f—� I—I <br /> Yp lJ Residue lJ Partial Rejectkm ❑Full Rejection <br /> 181h.Alternate Facility(or Generator) Manifest Reference Number. <br /> J <br /> U.S.EPA ID Number <br /> U <br /> < Facility's Phone: <br /> 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> t3.Hazardous Waste Report Management Method Codes(ie.,odes for hazardous yraste treatment,disposal,and recycling systems) <br /> 4. <br /> 20.Designated Facility Owner or Operator,Certification of foceipl of hazardous materials covered by the manes eexcepl as noted In llem 183 <br /> Prinledflyped Name Signature Month Day Year <br /> s are obsolete. <br /> EPA Form 0700.22(Rev.3.05) Previous edition <br />