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' ��3�r7�� I�I�II�III'I'I�I'I'IIIIIIIII'I�IIIII' C�( 0061369185 KS ?lease print or type.(Form designed for use on elite(12-pitch)typewriter.) ( Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Pf 3.Emergency Response Phone 4.Manifest Tracking Number (�++ (:AI_idt�fZ►3 :-,:as�9 SKa7 WASTE MANIFEST 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) \L LES'; Rt.t?i1,el- IPC. 8830 W Linne Rd TpACY CES 1530,= s .3 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number -1J T PnNMENTAL SVC INC, 8.Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL U.S.EPA ID Number 2247 S HIGHWAY 7I KIMBALL 72,v,A_'37�9--401, Facility's Phone: ya 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit p (' g p pp' g 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. NA3082, .,Z ARDOILIS WASTE. LIQUID, - z - o N.0.c, `?, Pe III �-{ IIOOV -T- a ' Z 2. + LU i -- `--T t9 ! E I 3. k j 4. , 14.Special Handling Instructions and Additional Information Ti I)FRG#t71• ��0�-n(� "4 FIR EMt;1 GENC.Y #1. �8�tD-468--1760 (SK i 'I"r I -nf17-N Tf' T(7r.f. 15.'GENERATOR SIOFFEROR S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offerors PrintedfTyped Name Signature Month Day Year X 16.1 erns al Shipments ❑Export from U.S. Port of entrylexit: r-- ❑Import to U.S. P Z Trans signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signatur Month Day Year U UJA►J ,� -�tt a�? 3 I ► , Qran-, r 2 Pr ntedlT�ed Name Signature I Month D� Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V rai Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Z Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1' 2. D 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature w1uW I Mon D r IM MCA vot EPA Form 8700-22(Rev.3-05) Previous edition a e obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRE )