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Please print or ofm designed for use On elite(12-pitch)typewriter.) Form Approved.CMB No,265n-6d39 <br /> 2-PagO 1 or 3.Emergency Responso Pnvne 4.Mar)es!�rackmn�Plumber �. �^ <br /> i.Generator ID Number -R t <br /> UNIFORM HAZARDOUS � Q�'� ��� �a�� 1�,-u:. -;'_:_, k- � �_, '�! � 4� <br /> WASTE <br /> MANIFEST Gtnmiors Silo P077 (itdiiferont than mailir<g addT+iss) <br /> 5_ �H till �i8'1O Ld Ma'Irng Rddress <br /> 3033 S-)"111 Wa <br /> SlKwarf,GAQUo6 <br /> 209-•234-7100u yJ?titier. <br /> Generator's Phone: r � ] <br /> 6-.Transpgrteri.CompanyName <br /> U.S.EPA Ip Number <br /> 7.Transporter 2 Company Name �,f`j r•. + � <br /> -� <br /> _. •' U.5,EPA ID fJurbar <br /> 8 t]aui alerrF,aGrity Name and Site Address <br /> q � 9512 M-1165 5011th 01 <br /> � t1 HVB 330010000 <br /> 776-553-2703 <br /> facility s Phone: <br /> t0,Containers 11,Total 12.Unit 13,waste Codes <br /> oa gh.U.S.DOT Descdptton(Alluding Proper Shipping Namms,Hazard Class,IQ Humber, quantity UVt.lVa1. <br /> HM and Packing Group(if any)) No. Type <br /> i$�2 <br /> 1. <br /> W <br /> 2. <br /> r31 <br /> C7 <br /> 4. <br /> f <br /> 14,Special Handling Instructions andAddibonal Information <br /> V" PPE ERG#171 <br /> Prose 0 12'c 300 - 25 Is i FERGENCY CONTdWT JEFF RHODES <br /> f 5.< G>rME#iA70R'SfGFFEROR'5CERTIFICATION: I hereby declare that the contents of this canslgnmenl are fully and accurately described above by the proper shipping name,and ate classified,packaged, <br /> marked and labele#lacarded,and are in all respects in proper condition for transport according to applicable international and national gavernrnentak regulations.If export shipment and am the Primary <br /> Exporter,I certify that the contents of this consNnment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> l certify that the waste minimization statement identified in 40 CFR 262.27(a)(it[am a large quantity generator)or.(b)(if i am a small quanlily generator)is True. <br /> gnaurer; / on ay ear <br /> Generator'siOfferc_rrs PmntedlTyped Name j � g <br /> 111/7 <br /> TIntemalional Shipments ElImport to U S ❑Export fromU.S. Por(of entrylexfl:ns orter si nalure(for exports only): Date leavin U.S.: <br /> W 17.TransporlerAMaMedgment of Receipt of Materials <br /> U-jg nature on ay ear <br /> Trdns orter 1 Printed/Typed Name <br /> . ids - 4 aj I I <br /> CL rgnature Month 1)ay Year <br /> � Transporter 2 PrinledlTyped Name <br /> 18.Discrepancy <br /> Discrepancy lndication Space El Quantity Q Type Q Residue Partial Rejection ❑Full Rejection <br /> tdanifest Reference Number: <br /> U.S-EPA ID Number <br /> 161b.Alternate Facility(or Generator) <br /> J_ <br /> t#1. <br /> Facilil s Phone; Month Day Year <br /> C:3 19c.Signature of Aliemate Faeility(or Generator) <br /> a <br /> JR.Hazardous Waste Report Management Method Codes(l,e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. 4. <br /> 20.Designated Facility Owner'of Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in Item iSa i,1onl-h DIS Year <br /> Prinledrl d / r Signature <br /> ^ - DESIGNATED FACILITY TD GENE C) <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br />