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ilii � •,! i �:' ��: .. :., � .. 1 <br /> Please print or type.(Form designed(,4r use on elite,(12-pitch):typewdter.).,; Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS' 1:Generalar:ID Number', ti 2 Page 1 of 3 Emergency Response Phone 4:Manifest Tracking Number <br /> WASTE MANIFEST 8 :� !� . _ . .ter�°�f J J A. <br /> 5 Generator's Name and Matlgig Address '' - 6e4i€ratots 5 e°dress('rf different than mailing address) <br /> r <br /> Generator's Phone:(20q):. 3h-2141,5 777J 1/_ .) '/S y r��r/ Grd�. �J� °y't:,, <br /> 6.Transporter1 Company Name U.S.EPA ID Number <br /> iNICS EfvVdRtJNMEIqTM-SERVICe :IIVG;. v. st t35Sc� <br /> 7.Transporter 2 Company Name. : U,S:EPA ID Number <br /> B.Designated Facility Name and Site Address U.S:EPA ID Number <br /> IAN=El-AARCIA4ENTAL SERVICES II . _SS <br /> 1')15 kr:J141'fFi RIVER RD: <br /> v1 Fg, s:plr;fiAUEfi TO,iti.A.91,559I <br /> Facility'sPhone:915-37''1-57'47 <br /> 9a. 9b.US.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11:Total 12.Unit 13:Waste Godes <br /> HM and Packing Group(if any)). No, Type quantity Wt/vol. <br /> 1' It#ON KORA HAZARDOUS SNA aTE Shat 1E� fam,(]r`13h?iS) :. <br /> 0 <br /> �. 352D <br /> z 2. ,. <br /> W <br /> ca <br /> 3. <br /> 4. <br /> 14 Special,Handling Instructions and Additional Information / <br /> LErr L' <br /> Hi' [lt ERs:"€O E'E'I?hAllr.IW A.AND Ugr—APPRaVED PPE.,. <br /> E R. C'01�7fR\0TOP: R 't� S Ei;TVli'ONIVIEtrdT,�L SER IDES <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by.the proper shipping name,and are classified;packaged,, <br /> marked and labeled/placarded,and are!nail respects in proper condition for transport according to applicable international and national governmental regulations.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 EPAAcknowledgment of Consen <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)orj(p)(if I am a;;NI quantity generator)is true: <br /> Generator. Offeror s Print (fyp d Na a Signature Moth -0a <br /> 1<1 <br /> d A <br /> -a 16.International Shipments: �Date <br /> v❑Import to U.S, ❑Export from i1.S, Port of entity/exitTransporter signature(for exports.only): leaving U.S.: <br /> UW 17.TransporterAcknowledgment of Receipt of Materials <br /> E Transporterl 'ntedlrypedName Signatur Month Day Year <br /> (10 <br /> Z. Transporter Printed/Typed Name Signa re Month Day Year <br /> . <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑Type " <br /> El Residue ❑Partial Rejection ❑.Full Rejection <br /> Manifest Reference Number. <br /> 1.8b.Altemate Facility:(or Generator). .'U.S:EPA ID-Number <br /> V <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator)' Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G1. . 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except'as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Re q5) Previous editions are:obsolete. DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) <br />