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Please print or type.(Form designed for-use on elite(12-pitch)typewriter.) _ - Form Approved,OMB No,2050.0039 <br /> UNIFORM,HAZAROOUS i.Ge mIw ID Number� 1 2.Page t of 1 Emew��$eeso Phone 4.htantfael Tracktn Number <br /> WASTE MANIFEST 1 111 1 009 92397 F L E <br /> 5.Gen-mWs Name and Mailing Ad dr Generator s Site Address(i different than mailing address) <br /> weRSAL Said;RRC'CUG, .INP1 lAftttti�t't't`tv4endottoa' <br /> 32W S,ED P�ltidu St, , <br /> Generators Phone'. <br /> 6,Transporter 1 Company Name.. U,S.EPA ID Numirer <br /> z <br /> T.Transporter 2 Company Name U,S EPA ID Number <br /> 0,Designated Facility Name and§fte Address U.S,EPA ID Number <br /> l X EnvimrnerlW Lfrca .a nal <br /> 1111'Wiest High -123 <br /> 1dd <br /> - 4- 1 asT CRrtiflri,UT 84,20 USA <br /> PP,nne: <br /> ga. 9b.U.S.DOT Description(indudng Proper Shipping Name,Hazard Class,10 Number, 10,Containers it.Total 12.Unit <br /> HM and Packing Group(4 any)) No. Type Quantity Wt"Voi, 13.Waste Codas <br /> :.. 4A � t1tr ' C ,•...: T 611 <br /> 4. , <br /> Y ? A <br /> x <br /> '14,Special HandlingInstructibnsandA ?40nai;trdofmabon <br /> r, <br /> FtK-YCLM PREM&' "t N, >+R <br /> tNSRRCRA, <br /> Rama <br /> X10 dt+d1 <br /> 16&W <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this oonsignment are fully and accurately described above by the proper shipping name,and are classified,packaged,' <br /> marked and labeladkplacarded,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 Ute attached EPAAdmowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 26227(a)(H I am a large quantity generator)or(b)4m a ail quantity generator)is true. <br /> Generale sF ami tedR N na ure ay Year <br /> GSL C f <br /> J 16.Intematimal Shipments <br /> i— ❑Import to U.S. ❑Export from U.S, Port of entry/am: <br />` <br /> Traosponers' ature(for exon(): x - Date leaving .S.: <br /> w 17: ransporl�rAo45cfgfiantdRartof , <br /> TranspalerT, dniedtTypedName' gnature un y'� a, <br /> CL <br /> ) t1 <br /> Z Transporter 2 Nnledffyped Name gnaWre Month ay Year <br /> 16,Discrepancy rr� <br /> 16a.DiscIepancy Indication Space ❑ Ousn6ty i_1-� <br /> Typa ❑Residue ❑Partial Rejection ❑Fai4 Re}ection <br /> Manifest Reference Number. <br />' i�. 15b.Alternate Facility(or Generator) U.S.EPA ID Number_ <br /> to <br /> ,,100.Slgitature afAlleniate FzcRity,t Generatoi) Mopth D Year <br /> x <br /> 19.Hazardous Waste Report Mans amen Method Colles We <br /> uy g codes for,tiazardalus�e treatmeht,'drsposai;2ndterydingsysdtns}" �" <br /> ca <br /> 2: <br /> - <br /> p' t �" <br /> L <br /> ated Facility Owner or Operator.Certifrcatm of receipt of hazardous materials covered by the manifest except as noted In Item 16a <br /> :d Name Signature Month Da Year <br /> EPA Form 8700.22(Rev,3-05) Previous editions are obsolete. DESIGNATED FACILITY TC)GENERATOR <br />