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da of Celil.mmlf <br /> le- eellh and Walters Agency -- —--- _— _- --__•-_ i Department of Health Seromas <br /> „�Approved Oy;9 No.2050-0039(Expires 9-3008) '� Toaie Subelancea Control Dwuion <br /> Snce.C n Control <br /> l Oa,' <br /> ao" <br /> r o or type (Form designed for Mae on safe Wfifth f Owner). <br /> UNIFORM HAZARDOUS 1. Ggnraetor'a US EPA ID No. Manifest 2. Paga I Information in the shaded are;,!; <br /> Document No. of is not required by Federal law <br /> WASTE MANIFEST -- <br /> ASlee 1,1.0030 Document Number <br /> 3. Generalor'a Nalop and Mailing Address <br /> , <br /> I G Z,N -St <br /> ^ UID <br /> Sta8. te 6enaretor'e ID <br /> Nf�mrlr C l <br /> 4 Genernloi s Phone�. ) [- - <br /> s Transporter I CoelpanY Name a. US EPA 10 Number C. late mna ones a ID <br /> D. Tran prior's Phos - <br /> 7 Transpr+rter 2 mepany Name 0. US P IDr u ben E. Stalerenappdar'o ID __- <br /> / F. TfenapoPsr'e Phone <br /> 4 Des,onaled Facility 'nmg and Siln AANeag 10. VS EPA ID Number _ O. Slate FIcII11Y a ID <br /> A CAI 1313 ici2 <br /> Lr.a �.GY'C• /I /!/A1. ../cz FecIIdY'r Pnpne <br /> / 13. Met 14. I. I <br /> 12. Conte 9 Unit Waele No <br /> Ouanlity ' <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) •v No 'type •`« Wl Ivo _ <br /> Stele <br /> a. 1 1 <br /> EPXIOt or <br /> F <br /> N SlelM <br /> 04 <br /> E b. <br /> R EPA/Omar <br /> A <br /> T Slate <br /> O <br /> I c' EPA/Other <br /> Stela <br /> d. -- <br /> EPA/Other <br /> K. Handling Codes for Wastes Lieled Annve <br /> J. Additional Descriptions for Material.Listed Above e. <br /> q I yqr <br /> L1hu�+ S GCS C'd l 6S/p'k/' ':nrT l47 a d. --. <br /> 1i <br /> 18, Special Handling Instructions and Additional Information <br /> ove by <br /> r h,Tvalli <br /> 8. <br /> GENERATOR'S CERTIFICATION: <br /> marked. and labeled.tend are in allllfrespectssin propenment ne condition re fully /oar transport by highwaccurately dos�rbecf daccodi np�e,Pill"�.d1lr <br /> name and era claational packed. <br /> international and national government regulations. <br /> 11 I em a large quantity generator, I codify that I have a program In place to reduce me volume end toxicity s10 ageeored disposal lcurrenly avail:tl 1 <br /> determined to be economically pecticable and that I have selacetl the a environment; <br /> nt; OR. o1ltam le small quantity generator. I have made a ".11 11 <br /> me which minimizes the present and future threat to human health end the environment; <br /> faith effort to minimize my waste generation and select the best waste management method that is available to are and that I can afford. <br /> Punted/Ty ed Name Signature <br /> a <br /> T 17. Tranaportor I At now nt of Receipt 01 Materials Month Day Y. <br /> R Signature i/ <br /> A Primed l Typed Name <br /> N <br /> S _ <br /> P tB Tr er 2 Acknowledgement 1 Receipt of Materials - <br /> Momh Day <br /> O 1• " <br /> Signature <br /> R 7 <br /> T Printed/Typed Name <br /> E <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 <br /> L _ <br /> M. Facility Owner or Opereter Oertilleelbn of recwlpl of hezardeua matedale covered by this manifest eaoept es .led In lem p 1, Month Dev <br /> T Signature <br /> V Printed/Typed Name — <br /> INSTRUCTIONS ON THE BACK <br /> (INS 8022 A(1/07) <br /> EPA 8100-22 YELLOW: GENERATOR RETAINS <br /> (Rev.9.88) Previous editlons are obsolete. <br />