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y os Gronco.nrint ni lyra rPnrm docinnod In; imp nn olito 119_n4rht fvno ifPr 1 i.:._.` J2 d 53554 , ITSC.i 01282. 0683 SC PPI 2/17/2010! Form ADDroved.OMBNo. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR flip -�Tit'tlSdbanhBStf'$i9pj;Y pnif`oN-t"fii55IGr?"A .r.; �.1 10 �..,,rt sslPrite.gre?Tzler?1'r flif)6t3ly', 10784.0601 UNIFORKHAZARDOUS _ 1. Generator 10 Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number 000024503 M W I WAS41161ANIFEST C A L O b 1 G 7 7 3 c 5, Generator's Name and Mailing Address Generators Site Address (if different than mailing address) FedEx I`rerat Inc STK A05 Faq2:3rd St I,`!piz 4520 aotO.. Fairy 99 Frena ge Rd .72'20 L tt4p Rock, AR �fi3r :Ci3ii, a0l 2 in Generators Phone: (4 ?7.L6 ;J7es ; �'? �t d FN ;4.t"Is RakP 6. Transporter I Company Name U.S. EPA 10 Number Gieatttlartmrs fnvtranmemallSo n-rcesInc in A rl G? q -.719 0 11 N n _ umber 7. Transporter 2 Company Name - U:S. EPA 10 Number- 8. Designated Facility Name and Site Address U.S. EPA ID Number 8. i Clean H -,J -bars A,raga tib LLC. I3' T O R 13 15 5 2 1-7 7 U800 Nenh An tus Road U1 Grantsville. IIT 94029 Facilitys Phone: t�t'2Kt sYo 9_42A !►n ga 9b. U.S. DOT Description(including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wtivol. 0 1. NONE. MON RC RA HAZARDOUS WASTE SOLIDS. (OIL DRY1� ?52 N;A 001 0M o� P z 2. w 3. f G 4. j fI I 14. Special Handling Instructions and Additional Information hate 1 PkO #11332121041256 1 ,CFiz '_164 61 {t(/0 0M 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, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent. I cei* that the waste minimization statement identified in 40 CFR262.27(a) (if I am a large quantity generator) or (b) (if[ am a small quantity generator) is true. Geneeratoes/Offerors PrintedlTyped Name Signature ? Month /Day Year } J R i,-.-1 ! F rf t C-' "`i r/� �� i::: A?yt'� f J ! l F (J _J t` i6. Intemational Shipments - !. ❑ Import to U.S. Expor4from U.S. Pont of entryJexft: Z' Transporter s gnature (for exports only); r •. Date leaving 11.S.: f W 17. TranspditerA mowledgment of Receipt of Maierials a Traosporter,1:Printed' y d e, Srgnatur = I c Month • Day Year':,, CL Z! dranspoiterPPiintedffyp'etlName` '. .' .... ,... `. .-.. _ ,Sigriatute' .•,.•-'r ..` ,, '+• :),.Month' ` Day. '>XeaF, 18. Discrepancy 180. Discrepancy Indication Space Quantity Type ❑ Residue ❑ Partial Rejection 0 Full Rejection f Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number U <t ' Facility's Phone: 18c. Signature of Altemate Facility (or Generator) . I Month Day. Year y19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) G 1' � 040 2. 3. 4.1 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 180 PdntedCTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR flip -�Tit'tlSdbanhBStf'$i9pj;Y pnif`oN-t"fii55IGr?"A .r.; �.1 10 �..,,rt sslPrite.gre?Tzler?1'r flif)6t3ly', 10784.0601