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I ease`prinfor type.f oim designed for use on elite(I2•pitch)typewriter.) Form Approved.OMB No.2050.0030 <br /> UNIFORM HAZARDOUS 1.Ganeretor1D Number 2.Page 1 of 3.Etbargancy Response Phone ; ' 4.Manifest Tracking Number —�° <br /> WASTE MANIFEST X7'17 � QO 1 <br /> 5.Generator's Name and Mailing Address A neratoes Site Address(d differeni frig address) <br /> ,Inc aInc „- <br /> .V coaft SSW 3M&E3 <br /> CABM StOMM,CA GM <br /> GeneraWs Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> kYP4= (&2MM6ftW`-EFN 100 8 747 <br /> 7,Transporter 2 Company Name U.S.EPAID Number <br /> � lh f.;t ' i<'r to ri L_ l..Oc Cry ' , > �� <br /> 8.Deslgnatad Facility Name and Site Address _ , f r 1J.S. ;P <br /> /*41 PAWS CXff I WA(--W, UT0994301748 <br /> Facility`s Phone: - q&t a <br /> go. 9b.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 Gmup(ff any)) No, Type Quantity WINOL <br /> w �• <br /> r <br /> 3. <br /> 4, u� <br /> 14.Special Handling instructors and Additional information <br /> DOMMiteird D4&=SEAM ONJW "M of <br /> 1 1 T - 174 — i— 0 6 <br /> Dwo —1 <br /> 15. GENERATDR'SIpFFEROR'S CFRTIFfCAT10N:(hereby declare that the contents of this cbftsignmerst are laky and accurately described above the proper shipping came,and are classified,packaged, <br /> -rho Xe'd an$labetadtpiacardec,and are-in all respectsin proper forfrar spariaecoiiUng interrtatfg tefand•natlork+f-gcsverrsmantatragu�tion4 if <br /> Exporter,i c,,*that the contents of this consignment conform erms of the attached EPA" Mnt'of Consent <br /> I certify that the waste mfninWzation statement identified in 40 CFR 26227(x)(ifl am a farge quant ty generate)or(b)(ff l am a small quantity r)is he, <br /> Genera` s P.rintedtf Name Signature / Month Day Year <br /> J 16.International Shipments <br /> F <br /> [1 p"tto U.S,. ❑Export fmm U.S. Porto enby/exit: <br /> Transporter signature(for exports only): Data leaving U.S.: <br /> 17.TransporterAc kn uledgment of Receipt of Materials <br /> LU <br /> T anspwtar l Pr sttadlryped Name Signature Month Day Year <br /> p _ <br /> j 7'j <br /> #sdAypad Name rwtureY ar <br /> IT/ <br /> 1a.thsctepancy <br /> E 18x.Dfsaepars p Ind cat on Specs ❑ Quantity t_!Type ❑Res due ❑Partial Reject ori El Full Re)acdet <br /> MantW Refarsni eMvber:. <br /> IBb.Altemate Facility(or Generator) U.S.EPA ID Number <br /> :3 <br /> til <br /> U<. Facility's Phone: <br /> w 18c,Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> 19.Hazardous tidasts Report Management fRatl od les(!.e, t iifloos waste b'satnent,disposal,aril recycling systems) <br /> O - <br /> ` <br /> t 4,_ <br /> 20.Designated Facility Omar or Operator,Certification of receipt of hazardous materials covered by the manifest axcept as noted in Item lea <br /> P' Y <br /> pad 2me ( s nature <br /> { <br /> t 7 th Year <br /> vai- <br /> .4 <br /> EPA Form 8700-22(Rev.M5) Previous editions are obsofete, DESIGNATED FACILITY TO GENERATOR <br />, <br />