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Z8,print or e. Form designed for use on elite 12• itch typewriter.) Form Approved.OMB No.2050-0035 <br /> P type.( 8 ( P )kYR ) _..RPr <br /> UNIFORM HAZARDOUS 1•Ge ton"' tJ her 2,Page 1 of 3.'),a�rg gstwnse Phone 4.Manifest Tracking Numt�er <br /> 7 } s $!" t( <br /> I -0,10631' 92D _ L <br /> WASTE'MANIFEST <br /> 6.Generstor'sName and MalingAd M GVCRECYCt1At Aitt.MflarhMeMOP nereta`sSiteAddress(ifditferentthanmailingaddress) <br /> H2O"S.El C)or-ddo St, <br /> Generator's Phone: <br /> 6.Trenspoder 1 Mpany ReU'S.EPA ID Number <br /> malmah Pacific ane-WCO <br /> NEDGG 17029 10' <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Now and Site Address 1 U 5.EPA ID Number <br /> 11111 -st '123 LITC-09201211201 <br /> . East Cwbm,LJT 84620 LISA <br /> Faci!Vs Phone: <br /> 93, 9b.U,S,DOT DesMpt on(including Proper Shipgng Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13 Waste Cods <br /> HM and Packing Group(if any)) No. type _ _Duantily WI Noi. <br /> 1 !•i11 <br /> r'r'z€�sawrsr.e tisr�:,e <br /> rO ta��rwrait.�c,°��w e^-as°-'�e.>+su:ri�€v ,ak,� <br /> wU' <br /> 3. <br /> 4, <br /> 14.Special Handling instructions and Additional information <br /> i , <br /> l#pa 4ER ALR CYVffJ l Rft 1..L1 t 1 }C /V�t <br /> L:GCIts�Y�tf 1 1E <br /> 18. GENERATOR'SIOFFEROR'S COMFICATION:I handy dedm that the contents of this corisigrinwt are fuii add accumfely ds=lbed above by thepn>pe€shipping name;and are caso6d;packaged, <br /> marked end Labe edlplacarded,and are in aft respects In proper cwdtion for transport aex tiift to applicable international and national governmental regulations.9 export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignmentoonixm b Wtarms of the attached EPA'A&W Md*wt of Consent <br /> I certify that the wsste minimization statement Warded in 40 CFR 262,27(x)(d l am a large quantity generatdi}or{b){if i am a small quantip enerator)Is trice. <br /> 59 <br /> nerator'sf mr's rin yped arae r nnawre I ear <br /> e 16.International Shipments <br /> #- ❑Import to U.S. Q Export from U.S. Port of entrylefdl: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> IX 17.TransporterArkmaMedgmant of Receipt of Materials <br /> LLI <br /> Transporte 1rPrin rySediNarrre <br /> -44 (� <br /> Z Transporter 2 PrintedJfyped Name s9lawre ay year <br />;j 18.Discrepancy I <br /> 18x.Disc epancy Ind cat on Space ❑ Quantity ❑T}pe ❑Residue Partial Rejection ❑Full Rejection <br /> Manifest Reference Number:. _ _..._ _._...... <br /> 18b.ARemate Facility(or Genaralor) U.S.EPAID Number <br /> Mt <br /> �- Faaf s Phona: i <br /> Lu M.Signature ofMamate-Fadi ty for Generator) — Month Day Year <br /> 19,Hazardous Wase Report Management Mata od Codes(is;;comes for hazardous waste treatment,disposal,and recycm'systems) <br /> LIJ 1. <br /> 20;Designated Facility Ow+r,or Oparetor,Cen fiction of racelptof hazardous materials covered by ifre manifest except as rented to item 18a <br /> PrntedTypedNamar <br /> Signature, M tIt Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete: DESIGNATED FACIGfTY TO GENERATOR <br />