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base print or type.(Form designed for use on elfte(12-pH6h)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generdtor 10 Number 2,Page 1 of 3.Emergency Response Phone 4.Mantfeat Tracking Number <br /> WASTE MANIFEST C,4i�"s O'5571 r t 415-823-8772 L <br /> 5,Generator's Name and Mailing Address Generators Site Address(If dMarent than mal trig address) <br /> Jfdit'ty � <br /> SVC REVY('1 JIG AIP,VAllam fAend618,4 <br /> } <br /> vWSC t)f?.CA 952% <br /> Generators Phone: . 209111311' S <br /> 6. ransporter ompany Rome US,EPA ID Number <br /> Uni is) r; I-A l 'CID <br /> 7.Transpoder 2 Company Name U.S.EPA ID Numbar <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Wu bar <br /> 'r.Lf •Id f3iFDs itYi�htrlt £f 1 l 2 bf 3 i <br /> )14 I tf :t Highway 1123 <br /> p-44144151 PaEr 11mbon,U7 84622 USA <br /> Facility's Phoria: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contafnera 11,Total 12.Unit, 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtlVol. <br /> 1 ts11 <br /> a' t f .'1-F�Y`.I���HAZAPL%:kUS,YVAST`E,SC)LfC (Isar rT'rt yt�t i�d`# X1 H11,11T <br /> Uj <br /> 3. <br /> r 4. <br /> s 14.Special t <br /> pea Handling Instructions and Addli-onel information <br /> stdIPL SeMdf0rREt CL IC�PROJE T RAILCAR <br /> t rtA SMeddV KQdf ? <br /> 15, GENERATOR11OFFEROR'S CERTIFICATION:t hereby declare that ftcontents of this consignment are fully and accurately described above by the proper shipping name,and are ctassified,packaged, <br /> marked and labefedtplacarded,and are in all respects in proper condition for transport according 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 the attached EPAAAnrmiedgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(ii am a anel quantity geryatatcx is true, <br /> anerat ro s rin Nam <br /> rra re P on y Year <br /> .r 16.International Shipments <br /> p Import to U.S. ❑Export frau U.S. Port of entrylea <br /> I <br /> TransWer,s"nature fbr exports only): Data leavi, U.S.: <br /> 17.TransporterAchnowiedgment of Receipt of Materials <br /> LU <br /> j' Transporter 1 dntadttypad Name 5nature Mordh Day— ear <br /> g� a <br /> Z Transporter Printecirryped Name nature ay ear <br /> 18.Discrepancy ��II <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type 0 Residue ' ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Altemate Facility(or Genarator) U.S.EPA 10 Number <br /> G1 <br /> LL. Facilt s Phoria; <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste ReportManagement Method Codes(i.e.,codes for hazardous waste treatment,disposal,and racyding systams) <br /> GW1 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operate:Ceit ation of receipt of fta materials covered by the manifest except as noted In Item 16a <br /> PrintedlTyped Name r 2 Year <br /> l /i 1 <br /> EPA Form 8700-22(Rev.3-05)`Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />;a <br />