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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0035 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3.Energency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST r=.d L t�tLl"5�a 7 1 41 -92 $�12 FL <br /> E- <br /> 5.Generator`s Name and Mailing AddressGenerator's Me Address(if different than mailing address) <br /> ?JNtf4'ER�RAL S,1G RKYC INN .Ain moff mor€ mz <br /> .4200' 8 0oracto St: <br /> _ �141Gttt4ff,4""� _ <br /> 6. <br /> r� Gedeiatne'sPhona: �� <br /> ra izporter 1 Company Name U.S.EPA ID Number r <br /> Union Pac <br /> T Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name Wand Addres U.S.EPA ID Number <br /> 1111 West Higlvwvy 123 <br /> 4dd•ddS1 East Carbon,UT 8,1520 USA <br /> Facility s Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13,Waste Codas <br /> HM and Packing Group(if any)) No. Type Quantity "Woi. <br /> i�rl r "u.f C wr fC T reg d) S#1 <br /> .. ® -e --k.... f9 f Y #8.r '...' :�i ,:.fir.: yr.,., r., �': 4.?'... 'r .: ... :. .Av.,... .r m«..•..a. <br /> '6. 2. <br /> LUk <br /> 3. <br /> i _ <br /> 4. <br /> 14,,Spersal Handling Instructions and Additional Information ' <br /> 7 RE-CYCLING f�fa s f�RHIGAft,�#C!. <br /> tHffi;�A� r Rn , <br /> ecar,pf t "116 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of[hisyrisignmentere fully and accurately described above by the proper shipping name,and are classified;packaged, <br /> marked and labeledtplacarded,and are in all respects in proper condition for transport a ing 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 thea ed EPAAdmowledgment of Consent. <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)('rf I am a large quantity generator)a{b)(d i am a small quant ty generator)is true. <br /> Gane tor's+0 —a Pdni Name gna ure A By ear <br /> AI) # 7 <br /> Vol, <br /> 0. f. . , <br /> s 18.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/ <br /> Transporter signature for exports only): Date lea' U <br /> w 17.TranspoderAcknowfedgmentofReceiptofMaterials <br /> Transporter 1-PdntedfTyped Name :. Signature. on ay ear <br /> t t t of <br /> Z Transporter 2 PdritedrTyped Name <br /> Signature t onth ay Year <br /> 18.Discrepancy -� <br /> 18a.Discrepancy Indication Space El Quantity 11 Type Q Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> Ll.r Fadliw sPhone: ., <br /> w"iBc;Signature ofNte+nafe:FacN ty.(of Generator) Month Day Year <br /> z' ••s. r, <br /> —77777 <br /> S 39:Hazardous Waste Report Management Method Codes(e eodes:torhazaidaulvasfa heaUnent d(sposatr.a?d rg�ycling systems).: <br /> n 1 uM 2:.'.., 3 4 <br /> 20.Des grated Facil ty Oman or Operator.Cart fiat an of irxaipt of hazardous mater adscovered by the mai.l. st except!is noted n item it3a' <br /> Pardedrryped Name Signe Month 7cT 4Year <br /> 1 <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. t` DESIGNATED FACILITY T4 GENERATOR <br />