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Please print or type.(Form desig—Ral art use ori elite(12-pitch)typewriter.) r Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Ga terator I()Number 2-f!0ge 1'bi<.3.Emergency espouse Phone d,Manifest Trackln Number <br /> WASTE MANIFEST C,'AL00035 37'17 1 #t-$23-977" L <br /> 5,Generators Name and Mailing Address ' Generators Site Address(if different than mailing address) <br /> ,UV'r €SAL-9VC K_C`i C1:KG 4t#T f Qit4ftlrCB <br /> �2�if�4ca 5 gl 7csT�do-'�+t:. <br /> Generators Phones:, <br /> 6.;ranapaterl mpanxNama. <br /> U.S.E AIOHumber", <br /> NEON 92.90 '.'. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> I'COG Enmrwnerdal UTCGO '1 220 i <br /> 1111 West X 123 <br /> Facility's Phone f <br /> casti--aftion,UT B462G LEA <br /> ga gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtIvol. <br /> q� 1,NOIN-RCRA RVMDOUSS WASTE,SOLD Mw-DOT regutaied`r 1101 H Tg 6i 1 <br /> t�... ,... <br />€ 2, .. FFF WWW <br /> E <br /> 3. <br /> d. <br /> 14;Special Ksis g(Instniclions and Additional information, <br /> RALCAR <br /> 15. 'GENERATOR'SIOFFERbl;S CERTIFICA71ONt t heretzy declare that the contents of is CCa9411171lent see fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and€abetp&placarded,and are in all respects lh 6wper rim cktion for transport aLAing to applicable International and natfonai governmental regulations.if export shipment and I am the Primary <br /> Exporter,l certify that the Cadenta of this consgnmentorm io the tarns of the at EPAAckrww adgment of Consent <br /> I certify that the waste minimization statement identilikil-0U CFR 262.27(a)(I am a large quantitygenerator)or(b)('d I am a small quantity generator)is true. <br /> Erator eror's Pnn yped(game Bignatu ` n ay ear <br /> a 16.International Shipmenl . Import to U.S. ❑Export from .S P hylexd <br /> Trans er s nature fez EX oni : <br /> w17 Transporter Acknowledgment of Receipt of Materials v ' <br /> 5 Transporter 1 Printedffyped,Nae _ gnature Y ear <br /> rt : .,: m a <br /> ;, r , <br /> Transporter 2 Printedfryped Name nature Month Day Year <br /> r <br /> 16.Discrepancy _ <br /> 18a.Discrepancy Indication SpaceQuanfiiy ❑Type ❑Residua El Partial Re)ection ❑Full Reject on <br /> N.aniifest Reference Number: <br /> 13b.Alternate Facility for Generator) U.S.EPA ID Number <br /> �. Facu" a'PhonE: <br /> y�yu <br /> 180' termite month Day, Year <br /> yyF <br /> 19.tiazardws Vtasie'ls'w Ma rogament tJteuwd Godes(i a codes fo{Hazardous waste treaf T>Ent dlspo ia)ar(re day slams). <br /> 4. <br /> a Designated Facility arimer or Operator..Certification of receipt of hazardous materials covered by the manifest except es noted M Item tea <br /> PdntedrfyW,Name Signature fJ Pt Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. <br /> DESIGNATED FACILITY T4 GENERATOR <br /> i <br /> f <br />