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ZIP6"t <br /> Pie 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.Emergency Response Phona 4.Manffeat,T kin Number <br /> UNIFbRM HAZARDOUS 02"772 t <br /> WASTE MANIFEST ��! 1.•1300 ?57'17 1 41 <br /> ELE <br /> 6.Generators Name and Meiling Address Generators Site Address(it different than malting address} <br /> IjM,'tRS.4f uVo F ECYG[jIN elft t ttfll 7t drid#1tfc� <br /> M1 Is Ell u <br /> ri0k.10Tf,tx,A <br /> Generators Phone: <br /> U.S.EPA 10 Number <br /> 6.Transpo ter t ompany Name <br /> EPA ID Number <br /> 7,Transporter 2 Company Name <br /> 8. <br /> U.S.EPA id Number <br /> Designated Facility Name and Site Address <br /> Ems.DC fivilf Of1YYlGTl i v L.4� �G1 l i <br /> i 111 Wesk Hi4tvNay 12 <br /> EVio-U4,4A51 FisiCaftion,UT 93526.E U <br /> Facility's Phage; <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ED Number, 10.Containers 11.10481 12.Unit 13.Wase Codas <br /> 9a, No. Type Quantity WUvol. <br /> HM and Packing Group(d any)) . <br /> 1 - .at r, r <br /> 1 <br /> O ' 1 { a;' .�id� '�t�z i a,t'ri�!t r, ..;{ t+tUrct7G <br /> d <br /> 2. <br /> to <br /> tJ <br /> i <br /> i <br /> 4 . <br /> 14.Special Handling instructions and Additimal informal on' <br /> lfdt F? +!Pfw r f UPJG CT Cat LG. QCs. g <br /> H0q,RCRP SWOdw <br /> t 6 } <br /> 15. GENERAiOR'SIQFFEROR'S CERTIFICATION:(hardly declare that the contents of this cons'sgnment are futly and accurately described above by the proper shipping name,and are class Sed,packaged, <br /> marked and iabeledtp',acarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and f am the Primary <br /> Exporter,I a rt fy that the conients of this consignment conform to the terms of ft attached EPAArlcnowiadgment of Consent. <br /> I car*that the waste minimisation statement Identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(d t apr a small quantity generator W a. � ay ear <br /> enaratorsf erors rot ', ro <br /> ..a 16.International Shipmentsimport to U.S. ❑Export from U.S. Port of entrytexit_ <br /> F- <br /> Z Trans der signature for a onl : IDate leaving U.S.; <br /> w 17.Trarrspaterfkc)aWWad9mentOReceipt fh4feriats <br /> poth ay ear <br /> Transrter l PdnW-ff' yped Nama gnature <br /> o } 1{ 1 <br /> CL on ay" Year <br /> QTransporter 2 PdntedlTyped Name lgneture <br /> r- <br /> 18.Discrepancy _ <br /> 16a.Discrepancy Indication Space Quantity ❑Type ❑Residue 0 Parffal Ro action Q Full Reject. <br /> Manifest Reference Number: <br /> 186.Nternate Fadity(or Generator) U.S:EPli1O Nrimmtier < <br /> J , <br /> U <br /> Fadfi 's Phone: Month Day Year <br /> Igo.Signature of Alternate Facility(or GenerateT} <br /> Q <br /> z <br /> 0 19.Hazardous Waste Report Management Method Crtles 0. codes fo[hazardous waste treatment,disposal,and recycing systems) <br /> C 1. <br /> 3. 4 <br /> EU 2. <br /> 20.Designated Facility Owner or Oparater:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a rionth Day Year <br /> Prini.d yped Name Signature <br /> IU .�� l-/ <br /> DESIGNATED FACILITY 7D GEN)=RATC) <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. <br />