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s� <br /> Ptease print or type.(Form designed for use on elite(12-pitch)typawritec) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator tD Numi er 2.Page 10` 3.Emergency Response Phane 4.Man t racktn Numhar <br /> WASTE MANIFEST CAl X10' 717 1 91. 3–i 732 ( L <br /> 6.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> UNKeRSAL Gid RECYCtAdAJA V41MM Mandena <br /> 32M S, 1 a <br /> oMon.CA <br /> Generator's Phone: <br /> Transporter 1.Company Name U.S:EPA ID Number <br /> Won Par&Um,CO NEOM17 1Q, <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6,Designated Fadlity Name and Site Address U.S.EPA ID Number <br /> ECDC ErMincinmentW UTC 09=2201 <br /> 11i1West HVw4W 123 <br /> FadlVs Phone. 1 East Carbon,UT 84520 USA <br /> ga. 0b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers %Total 12,Unit <br /> and Packing Group(if an Ouanti Wt Nol, 13.Waste Codes <br /> HM 0 P Y)) No., Type_ Quantity <br /> r, _r <br /> o r CRA H D �r a vu`e` ,s t`�tuFr�i�, m j 001 'y r' T 6f1 <br /> 2• <br /> 3. <br /> 4- <br /> %Special Handling Instructions and Additional.information. <br /> UN AL SEMIX RMYCLMP RA.1JCM NO. <br /> tt <br /> Nofl4t RA !16 t F/ <br /> t 8P <br /> 16. GENEftATOR'SIOFFEROR'S CERTIFICATION:i hereby declare that the contents of this consignment are_ ..end acwrately described above by the proper shipping name,and are classified,pedoged, , <br /> marked and labeiediplacarded,and are in all respects in proper condition for transport according to applicable inemationai 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 attadied EPAAdtnowledgment of Consent. <br /> I certify that ft waste minimization statement Identified in 40 CFR 262,27(x)0 i am a large quantity generator)or(b)q t am a small quantity.generator)Is <br /> true. <br /> GenotVslOffero s,not yped•Nameignw- <br /> -1 <br /> ay eat <br /> CJS rf i, <br /> 16.International Shipments <br /> Import to U.S. ❑Export from U.S. Port <br /> Transporter signature for exports on Date lea <br /> 17.Trartspodar�#enCCF ecarpt.of s a ;,.R.M x r <br /> j 12 Transporter i Printedffypod Name Signature '.. Month ay Year <br /> � +� h <br /> Zq— <br /> Z Transporter 2 Printedffyped Name nature Month Day Year <br />( 16.Discrepancy <br /> 18a,Discrepancy indication Space ❑ Quantity [:]Type Residua lett ❑Full Re ecton <br /> ❑ ❑Partial Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Fac; s Plane: <br /> C3 tBc;SignabrreofAttematoFacility(orGerrerato) Month Day Year <br /> 19,Hazardous Waste Report Management Mathod'Codas(a., fot.tiarardoir✓waste traatmant d sposal,`and rac_yd big"systems} <br /> l 1. 2. <br /> 20.Designated Facliitf Owner or Operator,Certification of receipt of hazardous materials covered b excapt as ribled in Item 16e <br /> Printedffyped Name i 'natureMor Daay� Year <br /> Cit,Y 1.-6B E wIG i. L <br /> EPA Form 00-22(Rev.3.05) Previous editions are obsolete. bts—ON—AAO FACILITY TO GENERATOR <br /> t <br /> l: <br /> 2 <br />