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1 <br /> RECOVED <br /> Pleasg print dr type. ' Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2 Page 1 of 3.Emergency Response Phone 14,Manifest Tracking Number <br /> WASTE MANIFEST WWW9=2 r 1W54Z3-Qffi I 019 4 4 5 5 5 9 JJ K <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Unwe im U1 111117 dM ISI Uibinatm Me 3W 4`41'W" 41tti1 rum L*emm Wimorof Leber 3'ttlQY ske 300 f"NNsA <br /> P.Q.900180/L-7W 4,IV6TiMM CA 94M COrTW H06GW R=ffntqr CA 9537 <br /> Generators Phone:925-4U-L%5 ATrN:Vdppkv, <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> fin Harbors Er virowilenW 5orvim Im M AM39822M <br /> 7 Transporter 2 Company Name U.S EPA 10 Number <br /> A <br /> 1 <br /> 0,Designated Facility Name and Site Address U.S.EPA ID Number <br /> ate liOM^8 DGtado LLC AROM748192 <br /> 3W AMersarl CUtle 9 DOMIJO AR 717M <br /> Faalilys Phone: 600'643"9720 <br /> 93. 9b U S.DOT Description(including Proper Shipping Name Hazard Class,ID Number, 10 Containers 11 Total 12.Unit <br /> HM and Packing Group{'d any)) ND Type Quantity WI Nor. 13.Wash Codes <br /> 1 Now RMA hwArd=Mme,mAd(1i Tum DOPORS5EG1 DM 794 P <br /> O <br /> W <br /> Z 2 <br /> LU <br /> C4 <br /> 3 <br /> 4 <br /> 14 5 aea_p _l H Yng�ns�ns aE�11D114 al 97_x• 205 C [l�3TIM3 L�1�r <br /> Ef11fT mergoxy Dutch.Load N UM9-(12,5idp Doc fib.S,247664. <br /> R dWaMts Ifde r MdW iXEMO on 1P15 Mkt, Q01MIN40,0003130M Q0030DUS 50�# )q OS-7 q 0j j g <br /> 15. GENERATOR'SJOFFEROR'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 labeledlplaarded,and are in all respects In proper condition for transport according to applicable international and national governmental regulations.N export shipment and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 1 certify 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 puantity generator:is true <br /> Generators/Offerors PrintedlTyped Name Signature Month Day Year <br /> Scott A.#:,e aEmlre oil b haN of t 1di1I5A tA f/� -7.4 <br /> _j 16 International Shipments ❑ .Impo . .rt to U.SU.5 Export from Port of enbyfexit. <br /> 6 Transporter signature(for exports only); Date leaving U.S.. <br /> LU 17.TransparterAdurovulgdcfinent of Receipt of Materials <br /> O Transporter 1 P Al yped nam/e• f , Signature• '7 Month Day Year <br /> y F r �' �l f' n <br /> �',� ' <br /> 7- Transporter 2 P_gktted,Typed Name Signature <br /> Month Day/ Year <br /> 16 Discrepancy <br /> 16a.Discrepancy Indication SpaceEl ❑Full Rejection <br /> 4uantity ❑Type ❑Residue Ell Partial Rejection <br /> Manifest Reference Number <br /> 16b,Alternate Facilityof Generaton U.S EPA ID Number <br /> J <br /> U <br /> Faditys Phone <br /> LU 18c.Signature of Alternate Facility{or Generator. Month Day Year <br /> a <br /> z <br /> 19.Hazardous Wase Report Management Method Codes is a codes for hazardous waste treatment,disposal,and recycling systems} <br /> Lu 1 cf^ 2 3 <br /> I/U A. <br /> O <br /> 20,Desicfn.lAd Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as nded in Item 16a <br /> ntedn r / Sigma° Month Day Year <br /> EPA form 8700-22(Rev 12-17) Previous editions are obsolete. f- I DESIGNATED FACILIT-YTO GENERATOR <br />