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D:TSC. 03734 0422 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Porto Approved.OMB No.205HO39 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 12.Page l of 13.Emergency Response Phone 4.Manliest Toddng Number <br /> WASTE M (svf2ww 014654605 . JJK <br /> Ad r s(i demai' <br /> 4�a t• ll9A nlnytF4 a k �y a d +CRs A4aF l�6 ¢n .� Nab y r, <br /> * ( <br /> . n Gecn1ere0Nrs•TPOMWrieh:- tr.y:nR:YOad 7rr J4PS�„4'?''.t arti•Y,:�4JA �.(`•r yl,f1`.car':y1''(ia�;v, <br /> ryOrlglGs '�q + Fy <br /> 6. <br /> - aal°n'�7S}C�t,OH(id:,GnTI'S <br /> CAr9SZ06�T'. <br /> Transporter 1 Company Name - U.S.EPA IO Number <br /> ?,0 y �?4PrOND.HGEPNIRQNMf(!(TAL`•SERV10z5.TING?tlFtlt�?Y:?��'�`-�3Ti�T'tra?> (i"31F?•xat-'`,a.w '?:;etikRiF"v�'fi.�,�FCrA+it0i0-0518b'73]a . <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> s��s;��tASBURTr_ENNRONMENfAIsSERVICESSitiii!r;ss;�;raw-,��.rPg��srr;��'.s�y, r(�!a"€+�??h` +t° 5I54�:CAdOZ•82'77.036 <br /> - 6• f e Address U.S.EPA ID Number <br /> . 3i(4Dp0',4-�plernetlaiSery'i - <br /> ,?D31F1Pmni/CAi907221x <br /> fadliHs Phone: ' ' vw>. xE?�1310)537-7r100i;ti{i4i„'F>ssrsfi'\W"�'7 +„tt�i. t5a"t :$F(i i§d$?.A� ct VXT4VV0&X315'2'- <br /> 9a. gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes; .. <br /> HM and Packing Gmup(i any)) No. Type Quantity WWoI. <br /> 1. s.;�fDQ1:8 1'3A:3 <br /> o; 3'>bN11308VF1a3mibo�arWasPrib" udativ'sR(Baortine);9.Pfrlll :xx^ n :r002i .:py(us':k*100,.+ 'w�' <br /> a .,•'r.'+$Mru'Ti'.'�'NyW.TF�L":,*14' Yir_rnk: <br /> z 2. <br /> W <br /> 3 <br /> 4. <br /> 14.5 I clions and Atltli5glal lnforma5on <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents afthis consignment are fully and accurately described ahave by the proper shipping name,and am classified,packaged, <br /> marked and ladeled/plararded.and are in all respects in proper candition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the a8ached EPAAckrowledgment of Consent. - - <br /> Ihat the waste mirimizabon statement identified in 40 CFR 26227(a)(d I am a large quantity generator)or (if I am a small qua lty generator)is two: <br /> Gene tors! ors P'n d/T Nwme signatureMonth Day Year <br /> i4ve zi ra a •tea - `r <br /> 2kohffnatanal Shipments <br /> ❑Impart to 0.5. ❑Export born U.S. Port of ethyl - <br /> Transporb r signature p expods only): Date leaven U.S.: <br /> W 17.TransporterAcknowiedgment of Receipt of Materials <br /> K T //r'1offI Print yIJQName I ✓ r Signabr Month Oay/ Year <br /> a <br /> /Ow t V1 �. J <br /> ear <br /> z Transparter2 d di Typed Name Si Month Day Y <br /> Q / <br /> t18.Discrepancy _ <br /> 18a.Discrepancy Indication$Paw ❑ aantity - ❑Type. ❑Residue ❑Par5a1 Rejecton ❑Full Rejection <br /> Manttest Reverence Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA IO Number <br /> J <br /> V - <br /> I Fadlitys Phone: <br /> W 18c.Signature of Allemate Facility(w Generetor) Monty Day Year <br /> Q <br /> 2 <br /> y19.Hazardous Wasie Repot Management Melted Codes 0.e.,codes for hazardous waste 5eabnent,disposal,and recycling systems) <br /> Wo _n Ar 2. 3 4 , <br /> 2g.Designated Facility Ovmeror Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 1 ntedffyped Name Month Day Year <br /> Q <br /> EPA Form 8700-22(Rev. 5) Previous editions are obsolete. : , . DESIGNA AC11 TO DESTINATION STATE(IF REQUIRED) <br /> 12284.0137 <br />