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i <br /> Please print or .(Form designed for use on elite(12-pitdt)typewriter.) Form Approved.OMB No.2050.0039 i <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 Emergency Response PhMe 4.Manliest Tracklnng Ntu�mlxpr© C <br /> WASTE MANIFEST r ! 006 22 8 8 2 3 F L E <br /> eater's Name and ftltng Address At t n:Carla 5 Mo s q u e dd enereta's to Address(9 diftotent ten maliirg address) <br /> Pep BOys#t711 <br /> •2099521222 4987:West Ln <br /> Generator's Pune: i <br /> S.Transporter 1 Company Nam U.S.EPA ID Number <br /> I 09a <br /> 7.Transporter 2 Coreg Name U.S. PA it) umber <br /> f <br /> S.Designated Fad0ty arta acrd Stte US.EPA 10 Number <br /> 8t er..icycl e,..Inc. <br /> 2670 Executive Drive ; <br /> Ind i anapo l i•s,•=I N • 46241 <br /> Fact s Pho a: 0 0 110197 ..._.. <br /> ga• 9b.U.S.DOT Description(including proper Shipping Name,Hazard Class,10 Number, 10.Containers it.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(d any)) No. Type Qu�1ty YAJVoI. <br /> a ''X 3-UN1993, •Waste%•Flammable.4 iquids, - n.o.s. 001. CF 00009 P • -000 :... 214 , <br /> (Acetone, Alcohols), 3, PG II, ERG-128 <br /> w <br /> X ?''UN1950,• Waste.Aerosols,.. [flammable, (each not 001 CF - 00025- • P. D00 2.14., <br /> exceeding 1 L capacity)], 2. 1, ERB-126 <br /> X VN1.956, Compressed gas, n.o.s. (Freon, Carbon 001 CF 00020 P 14 <br /> Dioxide), 2.2,. ERG-'126 <br /> 4. <br /> 14.Special Handling inslructonsadd Addilbnallnromatbn1.001PEP(Flaalmable Liquids) 2.002PEP(Aerosol5,••.Flammable) . 3. <br /> �.8 .ER(No n...F Laataab l e,...Ga s e s) <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are ruby and accurately described above by the proper shipping name,and are classified.packaged. <br /> marked and laboWpiacanfed.and are In at respects In proper condition l r transport acoording 10 applicable international and national governmental regulations.U export shipment and i am the Primary <br /> Exporter,I certify that the contents of ids consil;mnant contort to to torts or to attached EPAAdatonle figment of Consent. <br /> I certify trot the waste memmhaton statement identified in 40 CFR 26Z27(a)(W I am a large quantity generator)or(b)(t 1 am a small quwndly generator)is true. <br /> re e sPdn"Typad Kim Oth Day ear <br /> M. r1 Ad P41 Pat j <br /> 16.Intema' I Shipments <br /> ❑pmpon to U.S. ❑Export hen U.S. Port We,111*11 <br /> Tants r_.nature/or s Oate leav, U.S.: <br /> oc 17.rranspoft Acknowledgment aRecw of materials <br /> aTransporter 1 PrintedfTyped Name Signature MonlF Day Year <br /> Daf.ford..Mckenzie•,. Ian: 0 2.4..201 <br /> to <br /> Tran Pdnledlf Narrre rgnattxe y YW <br /> 1II.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity Q Type ❑Residue ❑Partial Re)ardion ❑Full Rejector <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) US,EPA 10 Number <br /> V <br /> W Fecili s Pbone: <br /> IIIc.Signature otAtemate Faddy(or Generator) Month Day Year <br /> 4 <br /> Z <br /> y19.Hazardous Waste Report Management Mailed Codes(tie.,codes for hazardous waste treatment,disposal,and redydirg systems) <br /> n 1. 2. <br /> 20.Designated FacrTity,Owner or Operetc Certification of receipt of hazardous materials covered by the manifest except as noted in Ilam i <br /> Prim Name lura M th Day /Year <br /> (III �6t C-!.& 1L <br /> EPA Form 8700-22(Rev.34)5)Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />