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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2054.0039 <br /> UNIFORM HAZARDOUS 1.1GenerateID Number 2.Page 1 of 3.Eme envy Response Phone 4.MarthstTrackln Number <br /> WASTE MANIFEST -:.''_fdiC� 17 94*� 25 372 <br /> 5.Generator's Name and Mailing Address Goneratoes Site Address(f fiert�il Than mailing address) <br /> tifinVER3AL BVC RECYCILM Ain Wntaixff;'see Ca- <br /> 2203 S,Ef Dorado St <br /> G$4cC toff,CA 95206 <br /> Ganerator!s Phone: " <br /> ransporter,l COmwy Norma U,S.EPA 16 MWr <br /> llnir fl.F s 1 rtff C0 <br /> L <br /> Transporter 2 Company Name U,S:EPA ID Number <br /> 8.Designated FacAly Name and Site Address U,S.EPA ID Number <br /> GN'Environmertalt T 1 3f3fi 9 <br /> 11 11 West Hiovvw, 123 <br /> 1 <br /> Ea5t Carbon.UT 84520 USA <br /> Facility's Phone: <br /> 90. 9b,U.S.DOT bescription(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity WLN01. <br /> t <br /> .I pi ., ' � ,�,,. �1 <br /> Ii ddb �Ft»eL.S.�. V'Yt4� ��NkUn'� f {f �� {. , j x .�,..::......�« '-. <br /> i <br /> Z 2. <br /> LU <br /> 3. <br /> 4, <br /> 14.,Special Handling Inshactions and Additional Information <br /> ECUC Pr r 1 1 ;7 X t <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION;t hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and ere classrfied,packaged, <br /> marked and labeiaed(placarded,and are In a$respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Pr Mary <br /> Exporter,I cari fy that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent <br /> I certify that ft waste minimization statement€dentfied in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(ff f m a 5mall quantity generator)is true.. <br /> Genemtoesf eror's 'nt yped am Signature n ear <br /> 0 <br /> .J 16.international Shipments <br /> 1 ❑Import to U.S. ❑Export from U.S. Port of entylexit: <br /> TraqspDrters: nature(for exports I : Date leaving U.S.: <br /> w 17:Trans entofRecgptafMatafsy J; : c <br /> Transporter 1 Prtntedtiyped Name knature r. t' ay ear <br /> IL I1C. 4'14 <br /> 4 Transporter 2 Printed.fTyped Name -4-.et Month w? year <br /> 18.Dis roparscy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Parti21 Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Feality(or Generator) U.S.EPA IR Number <br /> Facili s Phone:..:' <br /> 1 `Signature of Akamate Facit <br /> `'Year <br /> d <br /> 19.Hazardous Waste Report Management Method Codes(i.e cihdes for hawdous waste treatment d''sposa1,and recyir,ng spsUJ <br /> iems} <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as now in Item 18a <br /> rintedfTyped Name Signature h onth Day Year <br /> EPA Fan 8700-22(Rev,3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />