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�u fi�-1T145� �?� $�- � IIIIiIIIIIIIIIIIIIIIInIIIIiIIIIIIiN <br /> 0061939943 K3 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Ert_tprgeticy Response Phone 4.Manifest Tracking Number <br /> e�[e <br /> UNIFORM HAZARDOUS t::iID9fli,413/Ai7-,8 LD. . r 1006193994 V I\V <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> rr..7,s Shop 10 01145 <br /> ,-10 5 Krohn Rd <br /> CA 55377-91. . <br /> Generator's Phone: P09-835-6779 <br /> 6.Transportgr.1 Company Name,tv`���� INC <br /> U.S.EPA ID Number TX R000013I20F, <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ,'I-FAN HARP01 '=; ENuTRONM NTAL SVC INC.. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTA T N U.S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 'ti, iri"' <br /> 5 E(nint.I"S , UT A4083 i1"rD99130174fl <br /> 435-884-8915 Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1-INCEN RC RA HAZARDOUS WASTE SOLIDS (NON _ <br /> o RCRA HAZARDOUS WASTE SOLID (ABSbRBF_NT <br /> AND COIL) ? <br /> Z Z. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TCh GM 7 F-.f;_F,ct;! CA47950 <br /> ?4 HR EMERGENCY #1-80171 -468-1760 (SK TFT) <br /> 15. GENERATOR'S/OFFEROR'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,p ckaged, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms 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)(if I am a small quantity generator)is true. <br /> Generator's/Offeror's Pri ed Typed Name Signature Month Day Year <br /> be Oq 20 17 <br /> J 16.International Shipmenf§ <br /> Import to U.S. Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> Ll 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> 0 '9100%F a <br /> J 1091 2 0 117 <br /> QTran PrintedlTyped Name Snnure,�VJ:� Month Day Year <br /> 1 46 <br /> Z !L <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest pt as noted in Item 18a <br /> Print�gp�F3l�ie Signal a oath �ay Year <br /> \J <br /> EPA Form 8700-22(Rev.3-05)_Previous editions are obsolete. DES I ATED FACILITY TO DESTINATION STAT (IF REQUIRE <br />