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V' <br /> Please print or type.(Form designed foe use on alit®(12-pitch)typewriter.) Form Approved.OMB No,2050.0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3,Emergency Rssponse Phone 4:Manliest ekfn um r <br /> WASTE MANIFEST CAL 3 717 1 41 823$772 110 117,38698 FLE <br /> 5.Generators Name and Mailing Address Generators Site ss(ff different than mallingaddress) <br /> S,Iii <br /> SlIkIctoft,CA MIX <br /> Generators Phone: <br /> . ransporter TCompany lama U.S:EPA ID Number_. <br /> unkm CS coxr. <br /> 7.Transpartar Co party Name' U.S.EPA ID Ntirtibbr <br /> Designated Fadifty,Name and ft Address U.S,EPA ID Number <br /> 11ii 'Alie A Highway 123 rr, rrn� <br /> Fadrtty s P 1 Gag Cotian,U t 14520 L6A <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers it.Total 12.Unit 13.Waste Cedes <br /> HM and Packing Group(d any)) No. Type Quantity WuVol. <br /> 1. <br /> ivr.:Nk-Ri; ODUS WASTE,S01M(-00T ra ) 031 F/a�. T <br /> w 2' _ <br /> co <br /> 3 <br /> 4. <br /> id:Specht Hang Instructions and Addidonai f m tion t - <br /> s <br /> ecW1 PfWAO a4iAs <br /> 15. GENERATaR'910FFEROR S CER7I FICATfGN i horeby dsd a tbst the oantenta of tti oonelpnment are fully andumio"dsacrbed effete t<y1tw proper WON name,and ard dasWM packaged, <br /> marked and Wbafadtptacardail,and are in all respects in proper oandlhan fottrairsporl accofdirrg fo app8eebte in@etnatkin@l enc!tat onal govemmenml regutatlons: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 EPAA*wMedgrwt of Consent <br /> I certify that the waste minimization statement Identified In 40 CFR 2U,27(a)of i am a large quantity generator)or.(b)'(t I amla smaBquantity.generator)is true. <br /> anerator ro s ratName ro <br /> ,O` ay ear <br /> 1—j 16.Intematbnal Shipments <br /> t:— <br /> 11Import10 U.S, ❑Export from U.S. Port of antrylexit <br /> Trans r signature for ex EI oral : Date feav U.S.: <br /> LU 17.Tm poderAclwMedgment of Receipt of Matede(s <br /> ransporter i Printed7yped Rama Signature y earCL <br /> . <br /> x <br /> Transporter 2 Prinfad7ypad Name n t� f Month kD ` <br /> aC �r <br /> 18.1Ysmpan,-y <br /> 18a.Discrepancy IndicaWn Space ❑Quantity ❑Type ❑Res clue Partial Ra}action ❑Full Ra**n <br /> Manifest Reference Number; <br /> 18b.APtemate Fadiity(cr Generata) U.S.EPA ID Number <br /> Fackf s Phone <br /> Lu 18c,Signature o(Altamatefacdity(or Generator) <br /> Month. Day Yoar <br /> d <br /> 19.Hazaakws Waste Roport Managomenl Method Codas II.e. liar ft®zardarg waste treaWint,drsposei;and <br /> +tg systems} <br /> Lu 1. 2. 3 4: <br />' 2D.Des gnatad Fedlty Cramer or Oparstnr C4rtffaation of receipt of hazardous materials coveted by the manifest except as now In item 188 <br /> r mad yped Nama ature <br /> MiN ay Year <br /> EPA Form 6700.22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br />