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Please print or type.(Form designed for use on.elite(12-pitch)typewriter.) �� ,. ;. Form Approved.OMB No.2050-0035
<br /> UNIFORM HAZARDOUS • enerator ID Number 2 Page i of 3.Emergency Response Phone;, 4.Manifest Tracid%STNumber
<br /> E MANIFEST CA Sri "'17 1 41 23-8372
<br /> 5.Generators Name amend Matting Address - GMmWs Site Address(if different than mailing address)
<br /> LWAMRSAL Svc RECYCLNG tin wumn (loftoa,
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<br /> Gs,hafatols Plxiise: '
<br /> 7rartspa .ltermpahyName ' U.S:EPAIO"hfpmber
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<br /> 7.Transporter 2 Company Name U,S.EPA ID Number"
<br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number
<br /> t easy i. ,UT 84520 USA
<br /> Fadlitys Phone:
<br /> go, 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 1t.Total 12,Unit 13.Waste Codes
<br /> HM and Packing Group(if any)) No, Type Quantity Wuvol.
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<br /> 14 Spocaal Hegd4rry tnstrilctimt anti AMI onai Information
<br /> . ^. y T RAILCAR NO.
<br /> K= 119 0" Cha60
<br /> 15. GENERATQR'SIOFFEROR'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 labeledtpPacarded,and are in all respects in proper condition for transport according to applicable international 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 attached EPAAcknowledgment of Consent
<br /> I ce"that the waste minimization statement Identified in 40 CFR 262,27(a)[d I am a large quantity generator)or(b)(if I arnA small quantity generator)is Inue,
<br /> Gane sl aror's dntedfryped ame gne ra ,(, Month Day ear
<br /> -71_r 16.International Shipments
<br /> ❑Import to U.S. ❑Export from U.S. Pat of entry/ex
<br /> Transporters nature fa exports on : Date leaving U,S„
<br /> 17,Transport-rAGaro uiedgmanf of Receipt of Materials
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<br /> Transporter t Printedfryped Name, nature n y ear
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<br /> QTransporter 2 PrintediTyped Name Signature Monin Day Year
<br /> 16.Discrepancy
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<br /> 18a.Discrepancy indication Space Quantity El Residue ❑Partial Rejection ❑foil Rejection
<br /> Manifest Reference Number.
<br /> 18b,Alternate Parity{or Generator) U:S,EPA 10 Number
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<br />' 1 ra btattema(6 Fars a(#enerata Morn{t Day -Year
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<br /> ,10.Hazardous Waste Report Mariagemant Hattori Codes p o.,codesYor hazardous waste troahnenl disposal;ani recycling systems}
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<br /> 20,besignatod Fa1,lity Owner or Operator,Codification of receipt of hazardous materials covered by the manifest except as noted in item 18a
<br /> Printed Typed Nama JJ�":®� ' Signature f M nth Day Year..
<br /> EPA Farm 8700-22(Rev.3.05) Previous editions are obsolete. t`WPl DESIGNATED FACILITY TO GENERATOI
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