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C VVIVI <br /> Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved, OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Pagetof 3. Emergency Response Phone 4. Manifest Tr inking Number <br /> WASTE MANIFEST C, AL 8 ik 0 4 0 5 5 8 5 1 ( 80014244 - 6881 011123632 JJ <br /> 5. Generators Name and Mailing Address Generators bite Address (it unterem than mailing address) <br /> ARA61ARK <br /> 75701 S. LONGE ST, <br /> Genemfors Phone: ( 269) 2'34- 01015 <br /> 6. Tmnsporterd Company Name U.S. EPA ID Number <br /> 7,Transporter Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> CHEMICAL '.@tr1:5iEFAVANA INC. <br /> 152451 OLD S MUNE ROAD C A T 0 0 f €3 4 0 1 _ 1 7 <br /> ESE i7LEP+iA I CITY C-A, 03259 _ <br /> Facility's Phone: ( 5591) .386mm- C1 J 11 <br /> - ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 18. Conlainere 11. Total 12, Unit 13. Waste Codes <br /> HM and Packing Group (f any)) No, Type Quantity Wl.rvol. <br /> 1. NON' RCRAHAZARDOUTYdASTE SC1UC+ di6iTC <br /> o - <br /> W Z. u <br /> 1 yg� <br /> 3. Y <br /> 14. Special Handling lnsWGions and Additional Information <br /> ! . $ F103}8$52 ` (f ! J (J t✓ r�lsfs <br /> CHEMTEEC c--bNTPAZT4CCN24117 <br /> 15. GENERATORSIOFFEROWS 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 labeiediplacarded, and are in all respects In proper condition for Mansport according to applicable international and national governmental regulations. If export shipmentand l am the Primary <br /> Exporter, I cannily that the contents of this consignment conform to the terms of the attached EPAAcknmMedgment of Consent, <br /> I certify that the waste mtnimlzation 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 We. <br /> Gann atorslOfierors Printed yead ame Signal Month Day Year <br /> —� 6, International Shipments - <br /> F. mpod to U.S. Ll Export from U.S. FOR of entry/exit <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> 17. TramporterAcknowledgment of Receipt of Materials ' <br /> Tm 1 Printedfly edSig in Month Day Ye r <br /> O <br /> Z <br /> QTrans rter2 Printed/lied Name bignatug Month Dy Year <br /> F <br /> 18. Discrepancy <br /> Ise. Discrepancy Indication Space ❑ Quantity ❑Type El Residue ❑ Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> i' 18b. Alternate Facility (or Genemtor) U.S. EPA ID Number <br /> U <br /> LLFadlityIs Phone: <br /> 18c. Signafure ofAlternate Facility (or Generator) Month' Day Year <br /> Q <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal; and recycling systems) <br /> ® 1, 2. 3. 4. <br /> 20. Designated Facility Owner ar .pemtor. Codification of recelptof haza dous materials covered by the manifest except as noted In ItelZASTINATION <br /> . <br /> Rdnted(lyped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 3-05) Previous _ tions are obsol te. DI�S4�N 4TED �ACO8'YdTE (OF R E®) '... <br />