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� � I Pleafprint or type.(Form designed for use on elite(12-pitch)typm"Q Form Approved.OMB No.2050-0039 UNIFORM FtA2ARD0U5 1'Generator Et)Number 2.Page 4 of 3.Emergency Response Phone 4.tlaaitest Tracking Number WASTE MANIFESTC 0, L O V8b o i 0 2—z 0 0 0 0 0 2 6 8 6 5 JJ K 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) C F.1 f"rexrt+�5 FL�It�q A -re-"EL J?L.AZ4 I ` .333 `4' C.6'nSL are-r& 1501 P. JAc- -rO14E R_D AM• SAL LAKE, v-r b 4 05LI � Generators Phone: — — -00 ► O G4.. 5 .bb 6.Transporter 1 Company Name U'S.EPA ID Number I Amp-:s ceJtLES tic- I✓A2 a00 7.Transporter 2 Company!Name U.S.EPA ID Number i 8.Designated Facility Name and Site Address U.S.EPA ID Number LJ f►sM M A.a ay E r4�N i, t aQ-Ter f 321 eA.r- ��crsw p�YS 4 Facility's Phone: (310) 2,17— 00 E ga 9b.U.S.DOT De-vApfion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.N01. a 1. 000 - QC1<k }}RZl►¢-at7 r 5 WAST- .3 t- 5 o l4 C m 14C)OO P [ ft3Eegc.4ss v'J c. � A3 SPE� I t I , 4. 14.Special Handling Instructions and Additional Information i w CA-Q 4 tov ES Air o ra EyE c4 ntrkG'T: I 15. GENERATONVOFFEROR'6 CERTIFICATION: l hereby dedere that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlptacarded,and are in all respects In propermnditian fortransport according to applicable international and national governments]regulations,Itexport shipment and I em the Primary � Exporter,I certify that the contends of this consignment conform to the terms of the attached EPAAcknoWedgment of Congent I cerft that the waste minimization statement identified In 40 CFR 252.27(x)(If I am a large quantity gen or( I am a small quantityr generator)is true. I e ars! rors Pri yped Name slurs Month Day Year a 16.International Shipments t~ ❑import to U.S. . ❑Export from U.S. Port of entrylexit: k Transporter signature(for exports only): Date leaving U.S.: IW 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrinIWITyped Name Signature Month Day Year d ��- aS;r , orJ > 29 0 Y . QTransporter 2 Printedrryped Name Signature Month Day Year ; t- 1 18.Discrepancy 18a.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection EJFuil Rejection Manifest Reference Number.' 186.Alternate Facility(or Generator) U.S.EPA ID Number Zi I ' V LL Facifty's Phone: Lu 18c.Signature of Xtemate Facility(or Generator) MDnth Day Year a 55 19.Hazardous Waste Report Management Method Codes(ie.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 2 3. 4. i 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 111a PrintedfTyped Name Signature Month Day Year f. } i EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED), t _ }