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Ar c <br />Pleasl%nt or type. (Form designed for use on elite (12 -pit ewriter ) <br />)X9rryiV/ <br />MNL1I I IV <br />Cd <br />6 <br />0) <br />FUJI mppmveu. VIVID 110. zuoui uJe <br />UNIFORM HAZARDOUS 1. era r 10 Number 2. Page 1 of 3. Emesp <br />Emergency Ronse Pho,. 4. Manifest Tracking Number <br />WASTZMANIYEST WHO ! a, '44 aiiAl 000894518 FLE <br />3IGen€mtors Name andmansigAilloress Geeratar's SiteAdmss(ifiiffenut than mailing add ss) <br />AN Ulrl C'tx.►►}1-► �11i3 waSkelj►vis�xx-I NN unbrQ, �tcat�j <br />►8�L[� �/�aflac,qu��� Nc>c�ehotcl �.t,Yttie <br />{G/y�iX <br />(�+J <br />Siakie.f <br />Ge brS�lun7�•%� ' ` �Ip�Ls� 85C) S R -fwd 5+. <br />6. Tra o er 1 Company Name J U.S. EPA ID Number <br />Oaf hnrcci n 1►i 1101 <br />7. Tran.Cormpany ly.$.§ r _ •�/ 7"_ <br />J rU'/S. <br />6. Designatetl Facility Name and Site Address EPAIDNumber <br />\R.411 Rarbor5 CnuironmentcLf �►IJIr-iz, 1oC. <br />IntIII F'A(1114/) <br />*I _ (/; (� n C, fj <br />Facility's P ons:, �i.T'I+1 Nu�y -'r l 1"l l l�', � � ISL '! l c (30 a35 f 1 t Q IC7l <br />ga, <br />HM <br />9b. U.S. DOT Descrlp6on (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if a <br />10. Containers <br />11. Total <br />Quantity <br />12. Unit <br />WtNol. <br />13. Waste Codes <br />No. <br />Type <br />a <br />,)) L ^^'' <br />.,y <br />ln <br />1 Ali► b1 {'y. 'obn-U.� ril <br />}- ilia � 14•w)) 3, Un I� I I <br />, )�G <br />T 14 <br />r <br />OI <br />of AnIc.SR�,^a��l,�l, <br />PcdhEa(ve.f <br />► wj,�l.yfltnl 5,P II <br />CF <br />U <br />(�. <br />3. (� IQt19 i�l ' �te. {rr�r.11 (71 t�J7rl(r,111•t�, +5. , <br />Tr Ct�t i3,WnIg4 <br />`nj <br />�P�� In ,e� rt w ,6aGli <br />4/y1, t'O IV IP C ID051c.1(39arlic 0.01 j <br />((j1 �kGi ly'1E Imzrt&)ejut 7,P4II <br />�I " <br />114AWSIx <br />Nip - <br />14. Special Handlilring Instructions and Additional Information <br />I)Cpp���I�F,.)NLI��tol r.X mt3C 1 3iCIla�toE.1sX3S <br />la i 13-U f <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are 6lassified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transpod according to applicable international and national govemmental regulators. If expod shipment and I am the Primary <br />Exporter, I cedify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I caddy that the waste minimization statement Identified in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (if I am a small quantty generator) is true. <br />s Offeror's Printed/Typed Ta -me hgna u ,r/Month Day Year <br />Il il. I �c�Gfi- % f3 D <br />16. Inlemational Shipments <br />❑Impartto U.S. El Export from U.S. Pod of entrylexit <br />Transporter signature for ex ds only): Date leaving U.S.. <br />17. TmnsporterAcknowledgment of Remipt of Materials <br />Transporter 1 <br />%Pfrinted[Typp�peed7NaWees f ignature Month Day Year <br />JC <br />T er2Pdnl !Type a Sidi .�,.j .� Monfh Year <br />L`, <br />Discrepancy18a. <br />I18. <br />Discrepancy Indication Space Elpuan8ty Type ❑Residue ❑ Pallial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alamos Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Q <br />" <br />LL <br />Facility's Phone: <br />a <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />z' <br />Hazardous Waste Report Management Method Codes (i.e.., codes far hazardous waste treatment, disposal, and recycling systems) <br />j I <br />2 P UL4� 3 Ff w <br />t ,�� J <br />4 (' lib <br />20. esignated Facilitypwner or Operator. Certification of receipt of hazardous materials covered by the me K t except as noted in Item Ise <br />RiN yPod nth Day Year <br />hJ TnN� '_ _ -j <br />EPA <br />Form 8700-22 (Rev. 3-051 Previous editions are ohsnlete. r,r�L..Lrr ... w�.reM.,•n.. <br />MNL1I I IV <br />Cd <br />6 <br />0) <br />