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'nt or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050.0039 <br /> IFORM HAZARDOUS 1.Genare or ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mantfast Trackln um <br /> WASTE MANIFEST aAi..000 3 7`)7 010 31937 L <br /> S. rator's Name and MaHingAddress Generator's Site Address(it ' than mailing address) <br /> E1kii�° R~ly! <br /> SVC,RE"Y' G, Ain k&1ffiWM MAftdonrE <br /> 3200 S,EI Duado St. <br /> Siooldon,OA 95 <br /> Genaralor's Phone: 2M41"-96t6 I <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Unien Padiv,Lines CONEUM37929tG <br /> 7,Transporter 2 Company Name U.S.EPA 10 Number <br /> 8,DesEgnatad Milty Nam and Site Address U.S.EPA ID Number <br /> ECDC EmftarrwaUTt i 2�Q� <br /> Faali s Phone. <br /> X44-4451 East ,UT 84620 USA <br /> ga, 9b.U.S,DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> [jM and PaddN Group(d any)) No. Type Quantity mjvd, <br /> 75� �0. RC <br /> 2. <br /> w <br /> c� <br /> t <br /> 4 <br /> 14,Special Harding Instructions and Additional hnfon—wtion - <br /> LNN*RSAL SERVICE RRCYCLM <br /> Noii-RCRA Gwedftr Resfte Vd 0 <br /> 16. GENERATOR'SIOFFEROR'S CERTtFICATiON:1 hereby declare that the contents of this consignment are fly and accurately desv%ed above by the propershipping name,and estclassified,packaged, <br /> marked and Iatw adlptaeardad,and ere In all respects in proper wtxiitlan for transport spading to applicable intenm5o ral and national"mmentai regulations.If export shipment and I am the Primary <br /> Exporter,I cartify that the contents of this consignment conform to the terms of the attached EPAAdawwiedgrnont of Consent. <br /> I earthy that the waste minknizabon statement idandfled in 40 CFR 26227(a)(d t am a large quantity generator)a(b,104pm small qua )is true. <br /> Generators-/ s Printeffyped Name Bignature <br /> t, N lonffiy Tear <br /> L =— ,Y 1 /01 710 11 A-- <br /> - ;�-� <br /> .a 16.Intamaticnal shipments ❑import to U.S. El <br /> Expert from U.S. POA of entrytexft: <br /> . <br /> Transporter s nature for ex Date 1 U.S.: <br /> � 17.Transporter d�NRt o�lda�r�s,,s,:; ��a„s -� .q.• a ��^ �; � . <br /> LU Transporter 1 PrintedlTypad Name a y ear <br /> t 114 <br /> Transporter Printed/IypedNam pnature Month Day Yesr <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type [I Residue F]partial Refectkxt ❑Full Rejection <br /> Menest Ra4erera Number.. <br /> 18b.Alternate Faddy(or Generator) U.S.EPA ID Number <br /> rs <br /> LL Fad[' 's Phone: <br /> 18c.Signature of Alternate Facility(or Ganarator} Month Day Year <br /> 19.Hazardous Waste Report Management ki hid Codes for hazardous waste heabnent,disposal,and rasyft systems) <br /> LU i. .. •-; 2. 3 4. <br /> - <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous maters covered e ma <br /> materials by thn fest except as noted In Rom 18a <br /> PdYPed Name ntedrr � ,1 Ignature � Month Day Year <br /> Ll <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESiGMTED✓ FAG! <br /> LM TO GENERATOR <br /> sY <br />