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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) , Form Approved.OMB Na.20500639 <br /> 'UNIFORM HAZARDOUS 1,Generator ID Number atTrackina Number p <br /> WASTE MAHtPEST'" <br /> L€�� 00� 717`, m �9'i 933 977 L <br /> 5.Generators Name and Mailing Address erators Site Address(if different than mailing address) <br /> [il�Ntt R SAL <br /> G REGYG13i 1ff l�ali?1R1tt I f3ttOnea <br /> S3Qi� I fit, <br /> alan.lR <br /> Generelors Phone: <br /> 6,Transporter 1 ornpany Name' a' U.S.EPA ID Number <br /> Umar,Pat,,&-kms CO p1 " 1 NII <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 /> CF) Ufa Enol rrrrit a nr9r <br /> 1.111 12'i us urb�t r ; <br /> Favi€fly's Phone, ' <br /> Klt-U4-44,51 East Carbon,UT 94620 USA � <br /> 9a. 9b.U.S.OOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HIM and Packing Group(if any)) No. Type Quantity WI.No1, <br /> f <br /> 1 W)N-RCRA l4Ar. dUKM WASTE,SOLID(i orp D aT r erg) ';t HG T <br /> � l <br /> w , <br /> 3. i <br /> F <br /> i4:Special Ha ling Instructions and AdditkiR Information' <br /> {IWERSAL SERYME KCYGUWPRaXCT RAIWAR NO, <br /> iT Wim# 1 SS J �' 0,92 <br /> 15. GENERATOR'SlOFFEROR'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 fabeledfplacarded,and are in all respects in proper condition for transport according to applicable lntemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I candy that the contents of this consignment conform to the terms of the attached EPAAckneiviedgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)4V am e.smal( city generator)is true. <br /> GesnenatorstOfferors Printecirryped Name glia use ay ear <br /> -' ' 1 ? 1;> <br /> --n 16.International Shipments ((��'t <br /> f- u Import to U.S. Export from U.S. Rod of entry/exib <br /> Transporters`nature for exports only); Date leaving U.S w';1, <br /> W17,Transporter Acknoviledgment of Receipt of Materials <br /> 12 <br /> TmnspotarYPdnted(iypadName 'Signature on ay year <br /> t& IS 1:10 1111 <br /> 0 Tmnspeder 2 Printedfryped Name Signature Month ay Year <br /> F <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity 1:1Type ❑Residue Partial Rejaction ❑Full Rejection <br /> a Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> U , <br /> i+- Fant' s Phone:-. 3 <br /> w I6c.Signature of Alternate Factry{or Generator) Montfl ,Day Year <br /> ,19.Hazardous Waste Reput..Managamant Mattiadg is{i.e wogs fit t>azardous waste treatment,disposal,and recycling sysfamS) <br /> Cn <br /> ® 1' 2: .. 3 4 <br /> } , <br /> 20.Designated Facility Owner or Oparator:Certificat on of receipt of hazardous materials covered by the manifest except as noted in Item{8a <br /> Pnnte47yped NameSignature r. Month Day Year <br /> EPA Form 9700-22(Rev,3-45) Previous editions are obsolete. DESIGNATED FACILITY T GGENERAYOR <br />