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Geneimols Phone 209-19,36-0i'l,`5 CA 99304-910c <br /> 1. it 1r <br /> '•i + �14on �� SYH7ENS INC, <br /> 7 transporter 2 Company Name U S.EPA ID Num x r <br /> I:LI:gW HARBQRS � TXR0000E11c05 <br /> ENV SVC INC. US EPAIDNumber <br /> `! Uesignaled Facility Name and Ste Addross <br /> CLEAN HARBORS HIGHWAY <br /> LNV I FtUfwMFI ITAL. MA 5O.-59322 y�r <br /> 2247 S li T Y 71 SERV ICES, IN us.EPA ID Number <br /> 308-235-40112 KIMBALL <br /> Facility's Phone: t NF 691 45 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, NP-D981 7235 1 3 <br /> HM and Packing Group(If any)) <br /> 10.Containers 11.Total <br /> 0 x 1' NA3082 HAZARDOUS WraSTF 12 Unit <br /> � No. Type Quantity WtA/ol 1's Waste Codes <br /> F- N.D,S. , (LEAD), 9, PG IIIb It?UTA, <br /> i:)Ni F DO�AF 223 <br /> W <br /> Z ; — <br /> 0 <br /> 4. <br /> 14.Special Handling Inslructions and Additional Information <br /> TSD.RP H11�t311%.7 F?1:11�r4c'9 z-,-. <br /> 1)ERG#171; C G <br /> E'4H•Eh'fERt3ENCY" l -468-17'0-L'H/SK/TPI-Contract r,et:air, d L� <br /> n i 1 tr <br /> auth <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the p ope shhippi ge ame,and are clas'si'fied,package 0 h 1 y <br /> a <br /> marked and certify <br /> t d/placarded,and are in all respects in proper condition for transport according to applicable inlemational tel <br /> national governmental regulations.If export shipment and am the Primary r <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)lift am a small uanli <br /> Generatods/Offeror's Printed(ryped Name% q ty generator)is t ue. <br /> Signature <br /> Month Day Year <br /> � 16.Inlemationa Shipmen[s � � <br /> ~ <br /> Li Import to U.S. I •` <br /> Z Transporter signature(for exports onl ❑ S ts <br /> Export from U.S. i Port of enlry/exit: <br /> cr y) i <br /> W <br /> 17.TransporterAcknowledgment of Receipt of Materials Date leaving U.S. —— <br /> Trdllsa' r 1 Printed/Typed Name <br /> O ' .10 <br /> _ Signature <br /> Qa -, '^ / Month Day Year <br /> Tan3porter 2 Pdnted ed Name <br /> tY Signature <br /> Month Day Year <br /> 18.Discrepancy 3 <br /> I <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantify El Type <br /> EJ Residue ❑Part al Rejection <br /> ❑Full Rejection <br /> I�:: 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> J <br /> U U.S.EPA ID Number <br /> LJ- Facililys Phone: <br /> H18c.Signature ofA7emate Facility(of Generator) <br /> Q <br /> Z Month Day Year <br /> NJ Hazardous Wase Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w <br /> 1. 2. 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification cifrel of hazardous materials covered by the manifest except as noled in Item 18a <br /> Printed/typed Name <br /> Signature <br /> I oh Oay `fear <br /> EPA Form 8700-22((Rev.12-17) Previous editions are obsolele. <br /> i)$�}3ffH90/1.7p1a3�ifi jENERdATOR'S INITIAL CIOPY <br />