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.K Sk "TV 2 5 78 A k 51 FJ <br />SL <br />Please gint or type. (Form designed for use on.elite (12-pitch)tpewriter.). Form Approved, OMB No. 2050-0039 <br />UNIFORM HAZARDOUS Generator m er age, <br />�Legggng_. S D <br />U 43 4, FLE <br />WASTE MANIFEST <br />5. Generator's Name and Mailing Address Generators SiteAddress (if different than mailing address) <br />St J-4 CAd �i�n PC- 3, t a RV s rjrt <br />14, 9 10 0, 'W H X11 <br />262 <br />Generadoes Phone: I <br />I. a U.S. EPA ID Number <br />iy�l t INC TXR0@008 15 <br />7. Transporter 2 Company. Name U.S. EPA ID Number <br />6 <br />B. Designated Facility Name and Site Address'U.S. EPA ID Number <br />ULF -IN JAAROURS SCM JUSE <br />llsp:t b�-RoytBSA ROAD <br />SAO,-! ASE ci) 133 <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description {including Proper Shipping Name, Hazard Class, ID Number, <br />10. Contalners <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.. Nol. <br />WN t-KRA HUAZARDOUR t0-IBUTE BOULDrL <br />p <br />.23 <br />2.• <br />4. <br />-4 <br />--T <br />14. Special Handling Instructlons and Additional Information 7 R 04 B 4 2 13" F A, 33@ F54 'C' <br />jr?, 9J 7 <br />AJ <br />.44 HE,' ENER NCV Wf SK T-1 <br />•-GE <br />PUTH AS' "ASE('•!T—FOR" BY BEM TO RETAIN, LICENSEDsLa). cmRIER's, AS jE3 <br />15. GENERATOR'S/OFFEROWS CERTIFICATION, I hereby declare that the contents of this consignment arefully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labelediplecarded, and are in all respects in proper conditio n for transpoft according to applicable international and national govemmental regulatlons. 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 Consent. <br />I cerllfy,tboho wist9jnhimization statement. Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or jb) (if I am a small quardity generator) is true. <br />Yeneratoeal roes P t5d/T a '51griature on Day Year <br />V.0 <br />-j <br />16. international Shipments <br />Ellmpbdtou.s. El Export from.U.S: PM of entrylexit, <br />Trans porte(signature for exports only): Date leaving U.S.-_ <br />17. Tr6nsporferAcknowladgment of Receipt of Materials <br />s <br />Trsrffpo ter 1 Prirted[Typed-NameSignature f Month Day Year <br />% <br />Transporter 2 Pri� d/T�yppd•pe- Signature Month DIYJ�ay Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity E]Type El Residue El Partial Rejection EJ Full Reisdim, <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />=]i <br />LL <br />Fadlity's Phone: <br />LU <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />19. Hazardous Waste Report Management Method Codes (I.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Q <br />1, <br />2. <br />3. <br />4. <br />20. <br />20. Designated Facility OmerqrQperator: Cedificafion of receipp6Yhazardous materials covered by the manifest exop1penoted in Item 18a <br />Printed/Typed Name Signature k.", <br />!21 <br />1 <br />EPA Form 8700-22 (Rev. 3-051 Previous -edirions are o60bfe. r)rQir.wATrn I:ArII ITV TO61 -RATC)R <br />