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1 a 0 0 <br />10 <br />Please print or type. Farm designed for use on OHIO (12 -pitch) pewfiler. <br />t. Generator ID Number 2. Page 1 of 3. Emergency R <br />UNIFORM HAZARDOUS 7yf fls1;�(r'r,?, 17"� <br />WASTE MANIFEST t - l; r n _ <br />5. Genamtor's Name and Mailing Address Ge <br />?-ii3RTli iilmwlti'i'I1Uit F)RIV TRUCK "H;:IP <br />TRA(.:Y +;:A <.3g37ri <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />A#'FTi-jif.r.E14 'SYSTEM INC. <br />7. Trsrlsportar 2 Company Name <br />i r 7,' e), <br />B.Designated Faceity Name anO SKU Address SAFETY--KLEEN "YSTEM:;, IHC, <br />i72V ('00PEN CREEV POAD <br />940-48 3-': 200 <br />FacNl s Phone: <br />ga 9b. U.S. DDT Dasefiplon fnduding Proper Shipping Name, Hazard Class, 10 Number, <br />HM and Packing Group Of any)) <br />Cr if 1'R�? WA�M, PLAMMABLE LIQUID'S, H. (1, S- <br />G AS (lL 1 NE <br />',GAS(lL1NE ) <br />3 UN1993 FG II ( D018, DIi01) <br />z 2. <br />w <br />;awl(#10-)'635"1.3 <br />OMB No, 2050.0039 <br />THU00650930 <br />U.S. EPA 10 Number <br />U.S. EPA 10 Number <br />+lf}!7 ti 18 <br />TK 'rb20,° <br />TXD1:17'7110 3;171 <br />10. Containers 11. Total 12. UnK 13. Waste Codes <br />No, Typo ouanllty MNol <br />1111 <br />70 P E10011 D000 D01A <br />1.13 0UT5 <br />000288250) <br />15. GENERATOR'SIOFFEROR'S CERTiF[CATION: I huroby declare 111811110 contents Of fts consignment are tully and aauratatydascr bed above by the proper shipping name, and aro ass ied, <br />marked end labeled/placarded, endive in all respects in proper condition for transport according to appllcabie intemationatand national govOrpmenlat regulethns. If axparl shipment and I am the <br />Expoler, I candy [hal Ore contents of this eopsignmonl contemn to the leans of the aAached EPAAckrawiedgment of Consent. <br />I Wily Thal the waste minimization statement fdan(Illed In 40 CF'R 262,27(a) (If I am a large quantity generator) or (b) (kl am a a all qua gV y generator) is true. <br />h 16.3nlernallonal5ldpmenls iJImport toU.S. ijErArl[rc^iL',S. podet8lftryfaxil: .__. <br />X Date Isav:ng U.S.: <br />❑ Partiai Rejection <br />U S. EPAID Number <br />6(21 n 4,r <br />❑ Full Re)ec11on <br />DESTINATION STATE <br />— <br />Transportersignature (lot exports only). <br />17. Trenspo,lor Acluwwiedgment of Recoiplof Malar'rale <br />a <br />TransQartea i Print ed Name <br />g� I <br />Traan_s"pox�rter2Pdnto Name <br />//] <br />18. Discrepancy <br />tits. Discrepancy lndicaliwSpace Ruenlily ®Type <br />��JResiduc <br />Manifest Refeterce Number <br />feb.AllerneleFacility (orGenerator) <br />J <br />V <br />FaolilysPhone: <br />0 <br />2E <br />18c Signatureo Altornalo, Facility (or Generator) <br />Z <br />10,11azardous Waste Report Management Method Codes (I.e,,, codes for hazardous waste treatment, disposal, and recycling systems) <br />t 7-1. <br />3. <br />20. Designs Facitiry Owner oz Operator: Certification of receipt of hazardous maledals covered by the manifest except noted In Item 188 s <br />Pnntodrryp d <br />Sgnaluro <br />EPA Forin l 8700-22 (Rev 3-05) Previous editions are obsolete. <br />J. ar: :1 r <br />DESIGNATED FACILIT <br />❑ Partiai Rejection <br />U S. EPAID Number <br />6(21 n 4,r <br />❑ Full Re)ec11on <br />DESTINATION STATE <br />