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7 ,9_xLt <br />Please print or type. (Form designed for use on elite (12-pitchoewdter.) <br />• Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS 1. Generator ID Number 4 "OL 00t 1 53 a. k.+4h <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tacking Number <br />WASTE MANIFEST <br />I -i3 i, -'s fi--1. 160 <br />00218 4387 SKS <br />S.0 ier om-Nameand Mailing Address Generator's Site Address (I different than mailing address) <br />.! t.. Kiri., I <br />.:1.; <br />'tf;? ;'•' lHE:M t_NI Iver, <br />ai zl;'r ';ifv CO. 93PIO <br />Generator's Phone: <br />5;Trahsportei Goinpany Name , jytiyy I Mr.. U.S. EPA ID Number T J r Of 01?10 5i 0r)310 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address + I I r " iSi_ t v , Y 7 i t-; i -0-.,. �' u N, :y 1 1 U.S. EPA 0 Number <br />i T G LaaF'E.R GIiF:Fi ifarl <br />DE NTON, <br />940—il83..p;cRQ 1"'D0-77€0 371 <br />Facility's Phone: 4, <br />gra, <br />91h. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group if any)) <br />Quantity <br />wt /Va <br />13. Waste Codes <br />No. <br />Type <br />N;JLiIINE;Sj'tr._, zut_!il <br />0 <br />Y a e+ <br />(MF::7li.If, r.i'i!R <br />3171 <br />0 <br />_ <br />w <br />z <br />2. <br />w <br />0 <br />3. <br />7 <br />4. <br />14. Special Handling Instructions and Additional Information '::rt= t I r..i Jq .SOM8l Ski <br />24 HR EMERGENCY i1OO... 468-1761111%S FETY-hit_EEN 941 QO <br />9K E1UTHID 1'1"' i _;t: 991.113SE00iNT I:tiRRTERSa, 40067, 4103C', t`82f729, 8539% 8738-3 <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 labeled/placarded, 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 terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 21 (if I am a large quantity generator) or (b) (HI am a small guantity generator) is true. <br />Generatorsl0fferoes Printed/Typed Name Signature =1 Month Day Year <br />t <br />- <br />J16. <br />i <br />International Shipments <br />El Import to U.S. ❑Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): Date leaving U S:: V <br />WW <br />17. Transporter Acknowledgment of Receipt of Materials -' <br />K <br />Transporter 1 Printedryped Name -- Signature. >' Month Day Year <br />N <br />GTransporter <br />2 Printed/ryped Name Signatures'- Month Day Year <br />r— <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantl ty ❑Type El Residue ❑Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility(or Generator) U.S. EPA ID Number <br />J <br />U <br />r¢i <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility(or Generator) <br />Month Day Year <br />t— <br />Q <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. <br />20 Designated Facility Owner or Operator Clarification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pnntedrryped Name Signature Month Day Year <br />t) <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />