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Please print or type,(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0030 <br /> UNIFORM HAZARDOUS 1'G d � y 7 2.Plage 1 of. �#EmenseiPhons 4.Manffest Trecktng Number <br /> WASTE MANIFEST �#�1 tC37=• 0 L <br /> 5.Generator's Name and Mailing AM_",,ER Rpt Svc R T GLWG �Aii Il ;��ii� nemfors Site dress(`d different than mailing address) 3 <br /> StoC' Ioil•CA <br /> Ganerator's Phone: <br /> 6.Transporter 1 mpany Nam }: U.S.EPA ID Number <br /> ni rt C1 c I nes GCS C3q 11'9410 t� <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Stte Addre U.S.EPA ID Number <br /> �C[7C:�it�it`Otlmet�d a rrr•nrr?>tl��$ua <br /> 11#1 �t 123 �Y:•_•vo <br /> 1300444-4451 fast k-,arc crit.UT 84620 USA <br /> Faciittys Phone: <br /> 9a, 9b.U.S.001"Descdption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity a1vol. <br /> 5 '"fb F9i' 1: : a.:. ±I <br /> o <br /> ill .MIrr�Lrllm.) t r Al,�VVASTE,SOLID r;Wtr-art;s ri?9LIiateatai skit KG T S1i <br /> W 2. <br /> to <br /> 3. <br /> 4. <br /> 14:SpeciaitiandlinglnsWc4ionsardAddidonal.fntonnatton <br /> t I'V RECYCLWO PRaJECT RAILCAR NO. <br /> RIC <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hareby dsclam that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and laWedrplacarded,and are in all respects In proper condition for transport aoxording to applicable international and national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms o!the attaotied EPA Acknowledgment of Consent. <br /> Ica*that the waste minimization statement identied in 40 CFR 262.27(x)(if t am a'knrge quantity generator)or(b)(lf I am a small quantity generator)is true. <br /> Genera rs! eror s riawf(ryped Name gra ure on ay ear <br /> QL <br /> .r 16,International Shipments <br /> Import to U.S. ❑Export from U.S. Pott of envylex'' <br /> Z Transporter signature(for exports only): Dots lsevi S.: <br /> 17.TransporterAcknowtedgment of Receipt of Materials <br /> Transporter 1 PrintediTyped Name gnsture n ay eat <br /> +� ,. 1 <br /> ZTransporter Printadlfyped Name Day Year <br /> 16.Discrepancy <br /> 18a.Discrepancy Indirat on Space a Quanfty ❑Type ❑Residue ❑Partial Rejection ❑Ful!Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Genbratot) U.S.EPA ID Number <br /> M.r <br /> v <br /> Fable 's Phone: <br /> 1&,Signature ofAlterrata Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report M2nagsm6nt Method Codes(i,e.,codes for hazardous waste treatment,disposal,and recong systems) <br /> LU <br /> 1. ) } 2 3. 4• <br /> 20.Designated Facility Owner or Operator:Cert`.�ication of receipt of hazardous materials covered by the iron fe :a apt as noted in Item 18a' <br /> Priniedi yped Name -month Day Year <br /> tf 4 <br /> EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />