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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050.0038 <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Manifest 7rackin Number <br /> WASTE MANIFEST CAI.000:3667'i 7 i 415-nM772 <br /> 6.Ganaratcds Name and Mailing Address p/+� 399 FLE <br /> Generalor's Site Address(rf different than mailing address) <br /> U'N1kar-R:wA1.S}l>4.+ROO'yWNG ,aftt 14Vdt#(IM Meador ma <br /> 9200 S El Dorado St <br /> sst(o'k.tol,G'4 <br /> Generator's Phone: rtr8 5d'� <br /> 6.TransportaFTCompany Name U.S.EPA ID Number <br /> NE0601?92910 <br /> 7.Transporter 2 Company Name U.S.EPAJD Number <br /> 6,Designated Facility Name and Site Address U.S.EPA ID Number <br /> r-i.DCfditf�fr <br /> I 1?'I 1t>?'-q zy 123 W`,093 012201 <br /> 444-445i EaK t rt,4JT 84520'USA <br /> Facility's Phone; <br /> ga, gb.U.S.DOT Description(nduding Proper Shipping Name,Hazard Class,ID Number; 10.Containers 11.Toai 12.Unit <br /> HI'A and Packing Group(if any)) No.. ' Type Quant ty yry Nd, 13.Waste Codes <br /> 1"11; <br /> o NCAI Pf'RA I9 A D+.aUS A5 a4: <br /> i . <br /> LU <br /> w 2' <br /> 4. <br /> 14,Spedal Handling insbu&ns and Additional Information <br /> R <br /> , <br /> 15. GENERATOR'StOFFEROR'B CERTIFICATION:d her*dedare that the contents of this consignment are fully and ac,uratedy described above,by the proper andpp rtg name,eitd are class lied,packaged, <br /> marked and labeladlp[acarded,and are in a.11 respects in proper condi ' fer tmnsport atco ddhg to eppdica&e dntema066ai and nationalgovemn ental regulations.If export shipment and d am the Primary <br /> Exporter,I certify that the contents of this conslpnmant wnform is the terms of the attadied EPAAckimMedgmmt of Consent <br /> I cetity that the waste aftmiiation statement identified in 40 CFR 262,27(a)(df I am a large quant[y ganeralor}a{b}(t l a small quant ty generator)is true. <br /> Genera MeS nnt8dJT ped'Name WgI14WI Monthay year <br /> .J 16,international Shipments ❑import to U.S. ❑Export tram U.S. Pod of entryiexft: <br /> Z Transporter sinature fore oN :_ Dateleavn U.S::,. <br /> 17 Tran rfickiiow <br /> Uj sports Padsjmentof RecelpE of Materials <br /> ffm <br /> Transported PJntediTypod ' e, <br /> ­Year <br /> .-,. �:. . <br /> z <br /> Transporter Z Pdniedrrypad Name <br /> UnaWm ay_ ear <br /> i <br /> 16.Discrapancy <br /> 168.Discrepancy Indication Space ❑Ctuantlty ❑7�® y r <br /> Ypa i_d,Reutlue ❑Partial kejact an LJ Full Rejection <br /> Manifest Reference Number: <br /> 16b.Altemala Fac idty or Generator} 115.EAA 1D Number <br /> .Yr <br /> L7 <br /> Fall' sP_hone:- <br /> t6c:SdgnatureofAftemaPaaid FFenamtor) Mond„ Day," Year <br /> d <br /> z ' <br /> T 19.Hazart ius VJssie Repeal his Mett"Codes.(ie.,codas for hazard0ps Waste treatment,3is i,and r <br /> 1. 2. ecycrng systems) <br /> 1 3 4. <br /> 20.Designated Facility Owner or Operator.Cartificaacn ofie iptaf haiatdous materials covered by the mart fesfezoaptas noted in ttsm-10a> <br /> P ntadffyped Name ti S gnature Month Day Year <br /> ( „ar <br /> « i / <br /> EPA form 8700.22(Rev.3.05) Previous edrhoris Are-Obsolete- <br /> DESIGNATED FACILITYT9 PENERATOR <br />