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Please print or type, Forrii Approved,OMB No,2050.0039
<br /> UNIFORM HAZARDOUS 1,Generator'D Number 2.Pap I of 13.Emergency Response Phone 4.Manifest Tracking Number
<br /> WASTE MANIFEST
<br /> i 1 415�82341772
<br /> CXV-C1 0 0 2 5 137"17 1 01001,05- 5907 FLE
<br /> 5.Generators Name and Maiiing Address Genomfor's Site Address(if different than maAng address)
<br /> tA'QIV0,'8AL 30.'REf,'YGILT Nr3 Atti tVllllarii?,{endown
<br /> 3202 5,L-A Dorada St,
<br /> Generator's Phone:
<br /> 6.Transporter I Company Nam U,S,EPA ID Number
<br /> Union Pacifil",Line5 CO N tE HDO 0 17 9 2-2!1
<br /> 7,Transporter 2 Company Nam U.S.EPA ID Number
<br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number
<br /> 11 i t'AhmHif
<br /> Ea5t Cxbon,LIT 84520 USA
<br /> 9a, 9b,U.S.DOT Descriptan(induding Proper Shipping Name,Hazard Class,10 Number, 10.Containers ti,Total 12,U0 13.Waste Codes
<br /> Haj and Packing Group(f any)) No. Type Quantity Vfiqjvol'
<br /> 0
<br /> Rf)ckls `-',CUID 6111
<br /> Uj Z Z
<br /> 0
<br /> 3.
<br /> 4
<br /> J-
<br /> 14,Special Handling Instructions and Add6onal Information
<br /> L1 r tt RL-(�Y 1 Nt',PRCQL-C'r RAU,CAIV,NO,
<br /> swqor'r
<br /> GOC; 21 q(N k3 qw,&I
<br /> 15. GENERATOR'StOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and BCCUFAtely described above by the proper shipping name,aid are classified,packaged,
<br /> marked and labe!e&placarded,and are in all respects in proper condilian for transport according to aWicablo internaborialland national governmental regulations.If export shipment and I am the Primary
<br /> Exporter, wl 01 that the contents of this consignment conform to the terms of the attached EPAAcknorMedgment of Consent.
<br /> I certify that the wasto mininula"lion:Ialoment identified in 40 CFR 262.27(a)(it I am a large quantity generates)or(b)(if I am a small quantity generator)is he,
<br /> Ptinted/Typed Name Signature y Month Day Year
<br /> 16.Intafrialional Shipments
<br /> Ellmpo*n to U.S. FIExport from U.S. PW of enttylexrr
<br /> Transpodersignahim(for exports oril,# Date leaving U.S.:
<br /> W 17,Transporter Acknos*dgwnt of Receipt of Materials
<br /> LLJ
<br /> Transporter I PrintedlTyped Narne signature Month Day Year
<br /> 0
<br /> (n ti
<br /> z Transporter 2 Printed/Typed Name Signature Month Day YeYr-
<br /> 18.Discsopancy
<br /> 18a,Discrepancy Indication SpaceQuantityElm
<br /> ❑Residue ❑Partial Rl)ectiori ❑rul Refection
<br /> El
<br /> Manifest Reference Number,
<br /> 18b,Alternate FacAty(or Generator) U.S.EPA ID Number
<br /> Fa,�lays Phone:
<br /> Wj 18c.Signature of N(emate Facility(or Generator) 1krith Day Year
<br /> Z
<br /> 19.Hazardous Waste Report Management Method Codes(i.e,,codes for hazardous wasle treatment,disposal,and recyding systems)
<br /> Uj I
<br /> 20.Desgnated Fertility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Printed/Typed Name Signature T M In I", --y6at-i
<br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. USIGNATED FACILITY TO GENERATOR
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