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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man'rfestTrackin Number <br /> WASTE MANIFEST CA 1 "r`r "0"~ 1 14'L`--[rA/- 'ire 013�2 5 507 FLE <br /> ',liiirrTir 'r'J J7�7YT-�Yi./f <br /> 5.Generolor's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 1wL •r�:��Y 1a1i'i�arltard <br /> [ 1 <br /> ��i t/h:�ii1�J E i�Jii/�{� �-r_ <br /> CA`9S x.,3 {dlaritet.dr �A a5jju <br /> Generator's Phone: 3JJ-+i1-4--E 43 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> Mas Erttirarrtjjerital ��t�ti { aAR0002195.&:, <br /> 7_Transporter 2 Company Nam U.S.EPA 10 Number <br /> InnaWOx &4YV4gqP i Ca-ORT&M 103 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> UECOLOGY NEVADA <br /> Hwy. e5. 11 Ves South JSea N N 001 000 <br /> B catty, NV 3 03 <br /> Facie s Phone: 775-553-2203 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 0 1 Nun.RC,` - Haairdairs VJc% e, "14101dPuffered rr7rrtuill1i <br /> i � 8 P <br /> L 2:Nun-R-.,RA! a:ardaus Waste:. Li4uid 5;;;3ititr2 Suffes) <br /> OF P <br /> 3.'JN3143,Vtaste HydrVgen peruxide and peroifyacetic acid DOIN Du`G2 551 <br /> � mixtures, �tAI7�IliPd, b,i s8!, H <br /> 4 <br /> 14.Special Handling Instructions and Additional Informationni;nnar t; M4523 // CC .��yy <br /> 1i 0700,32",4 -54, L.IZ', #12.0 <br /> =;r!79131 5,70-11127 ( x 115 1 Y,US <br /> 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, <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 EPAAcknowledgment 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'slOfferor's PrinledlTyped Name Signatu Month Day Year <br /> vt?4,�� a,, &C�,kc E-2*3 VA I Q�- 1 91 <br /> j 16.International Shipments <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 /> W 17,Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Transporter 1 PrintedlTyped N e Signature Month Dav Year <br /> O <br /> a <br /> Tran p/orter�2 Printe yped Name Signature hto h Day <br /> � ��[/, r r I� pCMy <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) MDNI Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI 1. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except ay%d in Item 18a <br /> Phrited/Typed Na Eli A I Signature Day Year <br /> yl k (,�(WktAZ- liq <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FAC ITY TO EPA's e-MANIFEST SYSTEM <br />