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Please print or type.(Form designed for use on elite(12-pitch)typewriter,) Folin Approved,OMM <br /> UNIFORM HAZARQOUS 1.Gannerator iD Number 12.Page I of 3 mergency,Response Phone 4.Manifes't}Tracckin Number c �} <br /> WASTE MANIFEST CA U0 6 �-' ��� (0" O .i U � Q ( 5 U G J <br /> 5.Gonerator's Name and Mailing Address ator°a 8,11TS Address(if different than mailing address) <br /> 4 xo-.;- t fir' <br /> i0vck, <br /> 8.Transporter f Cnrnpahy Name U.S,EPA ID Number <br /> George W. Lowry,Inc. CARWO047012 <br /> 7. rt 2 Company Name U.S.EPA ID Number <br /> TransZZ9 <br /> 8.Das{ dress U.S,EPA Q�1`g2-4 <br /> 27-30 E.13tn st, <br /> YUMA,AZ 8M <br /> FaclRy's Phone: 92$-344--9M <br /> ga, 9b,U.S.DOT Description(inciuding Proper Shipping Name,Hazard Class,ID Number, 10,Centelners 11.Total 12.Unit <br /> HM and Packing Group(If any)) 13.Waste Codes <br /> No, Type QuantityWk.Nol. <br /> I1. NON RCRA FUWAMUS WASTE i7olly d S<7 en Was)s <br /> Cr <br /> 2. I <br /> W I <br /> I i <br /> 3, <br /> 1 <br /> 3 <br /> 4. <br /> + i <br /> 14.$V6"instructions andAdditional Information C <br /> USE GLOVES INVOICE4 f7 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate€y described above by the proper shipping name,at are classified,packaged, <br /> marked and tabaiedlpfacarded,and are In all respects in proper condition for transport according to applicable intarnatlonai and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,f certify that the contents Of this consignment conform to the terms of the atkaohed EPAAcknowledgmert of Consent, <br /> certify that the waste minlmization statement Identified in 40 CFR 262.27{a)(if I am a large quantity generator)or(b)(if€am a small quantity generator)is tate. <br /> Generator`sXfferors Printed/Typed Name signature Month Day Year <br /> ..t 1.6.International Shipments <br /> - ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date feaving U.S.; <br /> 17.Transporter Acknowiedgmant of Recelpt of Matadals <br /> Transporter 1 Pnyd Nameke, Signature Month Day Year <br /> a (n . <br /> nsporter 2 Printodfryped Name Si ratuia <br /> re-,-, �� 9 Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> M.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA lD Number <br /> L3 . <br /> U. Facility's Phone: <br /> LW 18c,Signature ofAharnate Facility(or Generator) Month Day Year <br /> Kt; <br /> Z <br /> .19.Hazardous Waste Report Management Method Codes.(Le„codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. 2. 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator Certificalion of receipt of hazardous materials covered by the manifest except as noted in[tem 18a <br /> Printed/Typad Name Signature Month Day Year <br /> EPA Form 870022(Rev.3-05) Previous editions are obsolete, .,ES,1GN 1-ED FACK.1-ry -1,10 DEST'lt`(,'a110N ST", TE' <br />