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J <br /> /Pilease print or type.(Forth designed.for use on eifte(12=pftch)typewriter.) <br /> EAdd.. <br /> tor 10 Number 2:P a 1 of -3: �Ijorrn.Approved:OMB No.2050-{103f <br /> MGenermatof <br /> WNa....d <br /> a9 Emergency Response Phone 4. a5t_WTiw*1 fg' u r <br /> F1 L000355717 1 1 X23 3772 0- 06,58547-FLE <br /> Grx GeneretbesSite'Address('d ddferent then mail address) <br /> OMIT A,LS Aitt Mjafrf Momlon0a <br /> 3290 S.2 Dorado st <br /> u1£ICaf!gft,tart <br /> Generator's Phone: <br /> 6.Transporter 1 Company anteU,SSEPAiD Number <br /> tion v,i Lines CC) <br /> 7,Transporter 2 Company Name U.S.EPA 1D'Number <br /> 8,Designaled Facility Name and Sfle Address US.EPA tD Number <br /> CD � f3fY1@ 4s i tau $ <br /> 1111 West @ 123 <br /> Facility's P 1 sd`Czirbon,UT 91620.LGA <br /> 9a. 9b•U.S.DOT Descripton(including Proper Sh ppkrg Name;Hazard Class,ID Number, 10.Containers 11.Total 12 Unit. <br /> HM and Packing Group('d any)) 13.Waste Codes <br /> No. Type— Quantity Wt lbl, <br /> 1. i g.gg <br /> 1Ri C1,"*c'-i•. !fd'"#6 YY."'LYtC'feJ4>"YP` tAI <br /> vc7 i 4 <br /> o lana sx� r" cevu r by e c; ti+autik tr �i tt33 HG <br /> LU <br /> 3. <br /> 4, <br /> 14,Special Handling In tudons and Additional information <br /> UMreRIk.SEM4CE RECYCJAIG <br /> PIOR-RCR def e <br /> FCW,P"10 4041t6 OM <br /> 15. GENERATOR'SfOFFEROR`S CERTIFICATION;I hereby declare that the contents of this consignment ere My and sc urately described abovg by the propel shipp 4riame,and'ste classified+pard abed, <br /> marked and labeledipiacerded,and aro in all respects in propar:cor4tion for transport acoprdiog to applicable intemationa#and national govemmenta#rogulations,if export shiipment and I am the'Primary <br /> Exporter,I car*that the contents of this cxms�nment conform to ttte terms of Ste attached EPAAcknow#edgment of Consant <br /> I certify that the waste minimization statement Identified kt 4.0 CFR 262.27(a),(if I am a taiga quantity 96—",Pr <br /> _(b)(lf 1'am a smalE quantity ger aiata}is true.... <br /> _..._.. . <br /> Genemtor'sJO s nm ypedNamenor re Year <br />} <br /> f <br /> p 16.#ntemationa#Shipments <br /> i z <br /> F1 impart to U.S. ❑Export from U.S. Port of entrylexrt <br /> Transporter starraturs for exports on : Data U.S.: <br /> i7.Transpaner AG r�wiadgmeni of Receipt of Materials, <br /> - <br /> r rensporter t' yped Name ear .. <br /> Pen <br /> j Transporter 2 Printed/Typed ame - - ._... <br />( " on Year <br /> i <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Spica ❑ Quantity Type F]Reskfue 0 ParbafRs}ed on ❑Full Rejection <br /> i <br /> I , <br /> 18b.Aitemeta Facll ry(or Generator) U S.EPA10 Nirrtfiier <br /> U <br /> Faal 's Phone: <br /> w f 8c.Sktna aty ofAKemale Facility(Lr Ganaratcx) Month Day Year <br /> x <br /> 19.Hazardous 4Vasta Rep;xt Management Mefta Codes 0;e codas for hazardous waste trestment,disposal,aied rec} g systems} <br /> _- <br /> 2. <br /> i I a <br /> 28.Des grated Facility Owner or Operator Cartlficatlan of raced V hazardous materials covered trytlte nwsntfest except as r>Dtadtn t sp,t&2 <br /> PrintediTyped Name <br /> SOVIure Month Day-. ,Year <br /> ,f ( <br /> �. t � <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, p GtJATEO FAC(!I3 Y T®GENER4T8R <br />