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fi s <br /> p <br /> Please pffi or type.(Form desIgned for use ogelfte(12•pitch)typewnier.) Form Approved_OMB No.2050-0039 <br /> UNIFQl2111 HAZARDOUS I' Generator ID+Number 1 2 Page 1 of 3 Em®rgaxy Response Phone d <br /> tNASTE MIAI11FEST O A L 0 0 0 3 1 9 is 3 2 1 )424.930 �til� J J K <br /> 5.GenersNOarream ilAdt�ess Ga enalors$Te Address(if dffererct than rnsiing addross) <br /> P O BOX OM SO's <br /> �FROITGE RD <br /> 4?Rrt <br /> RIPCA 01603115; CA GM <br /> Generators Phone: M9 CQW21 i2 <br /> 6,Transperter t Campany Name US EPA fit Nurrhnr <br /> AS"Y EWRCN KEENTAL 5ERMCES C A D 0 2 9 2 7 7 0 3 6 <br /> 7 Transporter 2 Company Nem® USS.EPA IC Number <br /> 8.oesIgna:ed Fady Name and Sib? U.S.EPA ID Numtow <br /> � �� <br /> 2M NMjH AL9*MA$`1MT <br /> CCUUPTCNd �a ii 7—T 104! GA 9= C A T 9 9 0 0 1 3 3 9 2 <br /> Fact *s Phone. <br /> ga <br /> 9hL U.S DOT4escdption(including Proper 5hippkag Name,Hazard C ass,!D Number, 10 Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Padang G up(if any)j go Type Quantity wl.Nol. <br /> 1. <br /> WASTE CO Mgl1STtBLE LIOUD.Ni 8 S. (PiESEL WATER),3,LIN igm, <br /> PG III <br /> 2. <br /> W <br /> 3, <br /> 4 <br /> 14.Special Handt.ng Inshucdaas and Adrf9mnal lnlw ration <br /> NAERG* 90i MI MORLE#08i 'APPROMIATE PER"XVAL PROTECIM Ei PMMT <br /> 15 GENERATOIi'SIOFFEROR'S CERTIFICATION: I hereby declare that the Contents of the consignment are Illy and accurately descrdred above by the prayer stuppmg nein,and are dasslfled,Packaged, <br /> marked and fsbeledlplacardad,and are in allrespects in proper oantakm for transport according h apprxab%niernehonal end national goverrmnentol regulabsrts.tiexport shipment and 1 am the Primary <br /> Experfar,I mrffy that Ma ear'erds of Ns eonsigmrent conform to the terms of the Atlnr.hed EPA Acknowledgment of Consent. <br /> f ca;r*lira!the waste mirdmaation stalerant lderdihed In 40 CFR 25227(a)(f i am a targe quanllty generator)ar(b)(f I am a small qusndly genetatpr)is h'A <br /> Generalur siolferor's PrinlodfTyped Name Signsturo Month Day Year <br /> P <br /> _s 16IrdamalirmalShlpments <br /> F ❑Import to U.S. ❑Ewart from U.S. Pod of en Imal. <br /> Transporter%"lure(far exports only) Data leaving U S.: <br /> Ce 17.Transpcticr Acknowledgment of Remilol of MMerWr <br /> W <br /> Ttansporter 1 Pdntsdlfyped Name &icsnalum r Month Day Yesr <br /> ate. .f f � �•"� <br /> QTransporter2PrintediTypod me Sgnelure M" Year <br /> 8.Discrepancy l�-1 1 <br /> 'iaa.Usranpmrcy Indleagsn Space 1 F Quantity ❑Type ❑R,osidue ❑Partial Re,edan ❑Ful Rejection <br /> A!andest Reference Number <br /> 18b Allemate Fac,lity(or Generator) U.S CPA ID Numhar <br /> 40 <br /> LL Fadfitlls Phone: <br /> W 1 G Signoure of Atemale Facility(or Gerlerator) - hiorr'h Day year <br /> r <br /> d <br /> a <br /> 19.Hazardous Waste Report Management Methad Codes(I.e..codes forfaazardous waste Irealmanl,dlWS81,and recycling systems) <br /> Fri <br /> 11.11 o 2 3. 4 <br /> 20.Dozignmed Facility Owner or Operator:Cerhficelion of nwptpt of hazardous materials omred by the mandest except as noted in Item 18a11 <br /> PdntedfTyped Name Signature Monthay Year <br /> EPA Form 8700-22(Rev.US) Previous oditwns are obsolete. GENERATOR'S INITIAL COPY <br />