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Please print or type,(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050.0039 <br /> 1.Generator ID Number 2:Page 1 of 3 E e noY se Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS <br /> t.,.At-('00 X5571.' } f RW27 <br /> WASTE MANIFEST 0 L <br /> 5.Generalor's Nam a and flailing Addr Generator's Site Address(if different than mailing address) <br /> t i�.I�KSI?L� v'REGYc C Ain wilhafrf mervi0wal <br /> 3200 S,H Doradoi St <br /> Stabktoa,OA. <br /> Genarat&s Phonea,. <br /> B raFspa ter 1 Caxnpany eme U.S.EPA1D,Numbef <br /> `r 1 TtariSpcxt' Company Name 777 "U,S,EPA ID Number <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number <br /> F--(X '' rtviroran`nY�l 7 <br /> I i i Vxest V 123 <br /> 800444-44-131 Eala C,wbcrn,UT 845201, <br /> Facility's Phone: <br /> ga. 9b.U.S.DCT Description(including Proper Shipping Name,Hazard Class,ID Number, i0.Conlainars ii.Total 12,Unit 13,Waste Codes <br /> HM and Packing Group(dany)) Na. Type Quantity W Woi, <br /> 1i!-'-'UPCRAHAZAR0i US WASTE, OUQ(Nofs-C,01'regu ) CK)t L�r�pS� T X11 <br /> -r_ ri rugj - .. <br /> L <br /> 3. <br /> 4 <br /> Y4.SAacai ngtfissandAd�Ttinforrnation;` <br /> is <br /> x § <br /> Pty=f+M &411 d <br /> 15. GENERATORIVOFFEROR'S CERTIFICATION:I hereby declare that the contents of ihs signment are fully 4M accurately descn'tiad above by the proper_shlpping name,and are dassAW,packaged, <br /> marked and lab"piacarded,and are in all respects in proper condition fer transpod ding to applicable mfemat'wnai and national go4mmental nsgulations.if export shipnrant and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the terms of the a"EPAAcknowiedgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 282.27(a)(d I am a large quantity genaratoo or(b)(N I am a s=H quantity generator)is true. <br /> aerators( erors nM ame nature ay ear <br /> Alt)o iir4 11 1 1 amc ;. <br /> J 16.international Shipments <br /> `r ❑Import to U.S. Export hn U ePort e <br /> z Trans er s'nature for ez its on : Data <br /> w 17.Transporter Act nm#s0ynient of Recei0 of Materials : <br /> Transporter 1 PriniedAypedName fS nature ay ear <br /> Transporter 2 PnntedrTyped'Name nature Aon ay' Year <br /> 18.Discrepancy i <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type El Residua <br /> ❑Padded Rejection 0 Full Rejection <br /> Manifast Reference Number: <br /> 18b,Alternate Facility(or Generator) US.EPA 10 Number, <br /> J- Fadf.s Phone:; tiP5, � . <br /> us <br /> 10c Sgrtafura eFafwGenerator) "p rt Month Day Year <br /> NaslgRepartMe(acanshttet_hadCooese fcazardotrsyaa�5alme(t qd sysfegtg);�a t <br /> , <br /> 20:pasu,natea Fac tidy Comer cr!?pe ator Certifx at caof racxlpt of hazardous manna-s covered by 1}pa tnandest exert as noted in item 18a <br /> PnntedtTyped Name 5gnatura Month .-Qgy Year <br /> j EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br /> 4 - <br /> 1 <br /> C <br />