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Please print or type.(Form designed fq,;se on elite(12•pitch)fypetvnfer),. Form Approved.OMB No.205D-0039 <br /> UNIFORM HAZARDOUSI"-GeganatorlD Humber 2.Page 1 of 3.Emergency Response Pfrona 4. ani racking Number <br /> WASTE MANIFEST 4 X57;17 1 415 X277 12172449, FLE <br /> 5.Generatx s Name arta Mailing Address. Genstatoes Site Address(H different than mailing address) <br /> t.}9}!#r/�R ,'kle:�41�i� C�GI.1id� :4Ytt�t1H1am 1xlasled <br /> Gensraton`s Phone: <br /> ransporter i mpany ame U S.EPA'ID Number <br /> Unfm Pacific Lines CO <br /> .Transporter 2Company.Name U,S:EPA 1DNumttr, " <br /> 8.Designeled Facility Name and Site Address U.S.EPA ID Number <br /> KW BwirowentW <br /> W11O I <br /> (111 WoSt ftway 12, <br /> Fad6 's P - -4 I r-afat CBr�aan,� 84520 LLSA <br /> 9a, 9b.U.S.DOT Description(nctuding Proper Shipping Name,Hazard Crass,ID Number, 1iP Containers• 11.Totel 12.Unit, 93.Waste Codec <br /> Hh1 and Pacidng Group(d any)) No. Type Quantity Wilm, <br /> 1. <br /> �"• res n:ora.^+m e+r-ar <br /> a!^t}t s ,:}L>Z�tr�li�l.t d [Q w �� Cltl� t� J� .. <br /> 9 IL x'3"PSt�t�,4�rP"L�4iJ"Lr'�SJLd��'WAS r$.,> <br /> W <br /> t9 <br /> 3. <br /> 94.Specai Handlingshucdonsand Atld tlor al informaiSan <br /> Oc,IfR,AAL ERIE RECyCt_jtjQ pRaJ Cr P,auc.ARWO 5 'C7 } ,�/O 9� <br /> wift—nRA%"dder Rerfact4 <br /> ECW.PrORWA0411 <br /> 15, GENERATOR'SIOFFEROWS CERTIFICATION:I hereby declare trial the contents of this consignment are fully and eocutetefy described above by the proper stopping name,and are classified,pa&e*, <br /> marked and labelediplacarded,and ara In all respects in proper condition for transport according to applicable international and natlonal governmental regulations."export sNpment and I air;the Primary <br /> Exporter,I certify that the contents of this(consignment confINnn to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(i i am a large quantity generate)or(b)(91 am a small quantity generator)is he. <br /> Ganerator'sl0hroes rinted,iypsd Name nor reat ay ear <br /> /4 <br /> .j 16.International Shipments <br /> ❑import to U,S. ❑Export from U.S. Port of entrylexit <br /> Tmns22rter signature for export only): Date WAN U.S.: <br /> rY 17.Transporter AdToMedgmentofReceipt ofMatedais <br /> jFes— Transporter 1 Printedflyped Name nature <br /> � <br /> O + y <br /> Year <br /> zIL <br /> Transporter 2 PdntedJryped Namenature i.:. <br /> >e Day ear <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑PrrUal Retectbn ❑Full Relaction <br />` MaNdfast Reference Number. <br /> 18b.Alternate Fadtity(or Generator) U.S.EPA ID Number <br /> fJ <br /> Facll' s Phone: <br /> ru <br /> 18c.S gnature ofAtlemate Facility(or Generator) Month Ray Year <br /> Z <br /> 19,Hazardous Waste Repoft Management Method Coles(i.e,codes for hazardous waste treatment,disposal,and recycling systems) <br /> t. 2. 3, 4. <br /> 20.Designatad Facility Owner or Operator:Certification of rev eipt'of hazafdous materials covered by the manifest except as now in item 18a <br /> Pdnledityped <br /> Name S gnature ih Day Year <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />