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i <br /> Please print or type,(Form designed for use on elite(12•pitch)typewriter,) 2-2 -11,51-)417-5`5- Form Approved.ONItB No,2050,0039 <br /> UNPRM HAZARDOUS 1.Oonerator ID Num er2.Pogo 1 of 3:Emergoricy Rasponse Phone 4.Mani{ast Tracking Number <br /> WASTE MANIFEST t'A!-Ii7���1'1.�+6-'.:,-1;rt 1 1 6�itl•_,,t,1�...1760 0 6"°`]' .13 SKS <br /> 5,Generator's Name and Mailing Address Generators Silo Address(if different than mailing address) <br /> ASS ti f+1 Wit[ 1 b7Tt 1n" <br /> 114 27th 5t' <br /> 0 Mell"FNl t) i r) `3 16. '.f'%7 <br /> Generator's Phone: .r 1 i..,, —lt� <br /> 6.Transporter 1 CompanyName U.S.EPA ID Number <br /> EE <br /> S;a: E'rY—!'.L 111 SYS rEZ-1 a" �X i �s 'Js�,)1 03 <br /> -- -._ <br /> 7.Transporter 2 Company Name I U.S.EPA ID Number <br /> t L i PN, I!t"WBOIRi �:NVZxf.rel�Eb1TPL. `YC Dit L y' <br /> 8.Designated FacilityName and Site Address U.S.EPA ID Number <br /> I'I,Fi•tn) HARKIM3 TAN ,1 OC <br /> 021 DER1R`1F 1;SP 'PT'A 3 <br /> Faciilly s Phone: 14 10 6-1.14 I--lo"Ji.7 F` CA 9-;133 <br /> go, 9b.U.S.DOT Description(inefuding Prop r Sh pping Name;Hazard Class,ID Number, to.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) ? No. Type Quantity WLNoI. <br /> t. <br /> �- :J�" E-1 Rt?I�F M HY�.T�t C&,LGtN- 7,r � Lz Hi 2. ,.. <br /> 3. <br /> D <br /> a� <br /> a. <br /> %Special Handling Instructions and Additional in ormltion r y <br /> r h t i 1 iwi i7 313.j 1r� <br /> » <br /> 10 <br /> c;4 H0 ERaF 1 1780 (a : T) <br /> 15FER FPSCE I fCAIi �rdb ride ro idf $ro3`GN0 t1 h f bW <br /> drt b ty a accuiat I bad'a o 6 rifle P=r 141 ng name,and are classified,packaged, <br /> marked and labeletllpiacarded,ond:are mall.espeicls in proper condition for transport aecording to applicable Intemallonai and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this con Ignn ant conform to the terms of the attached EPAAckno>< dgmenPnf Conseg <br /> fy that the waste minimization statemoliden l0ed in 40 CF 26Z27(a)(if I am a large quantity genera.r or(b)((f i�n small qu ntity gonerat is Due. <br /> enorglor3, ror's PrintediTyped Nos tur 7. Month Oa Year i <br /> F 16.1nternaUonai Shipments El foil U.S Import ❑Export from U.& PogVloxit, <br />( Transporter signature(for exports only): ate Ioavlpg U.S.: <br /> z17.Transpo erAcknowledgmentofRooeiptofMate late ✓ <br /> Trans or Pd ad pe Name Sign fo "I Monlh Day Year <br /> CL <br /> QTransp nnl. !typed Name Signature Month Day Year <br /> 7121?.. - . <br /> 18,Discrepancylee <br /> 18a.Discrepancy indication Space. Qua ti <br /> ty F]Type F]Residue ❑Partial Rejection ❑FaIi Rejection <br /> 1 Manifest Reierenca Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> W Facility's Phone: <br /> UJ 18c.Signalure,of Alternate Facility(or Generator) Month OayYear <br /> z �* <br /> 1g.Hazardous Waste Report Management Method Code i(Lo.,codes for.hazardous waste treatment,disposal,and recycling systems) <br /> L 1 2, 3. d, <br /> 20,Designated Facility Oti ner or Operator:Certifica ion o recd( hazardous materials covered by the manifest except as noted lit ltem 1¢tl ,.f <br /> Li 4�— <br /> PrintedfTypd Name rr' f �Signature � / Month Day Y ar <br /> FPA Forrn 8700.22Rev.3.05) Previous lo..,re bsoT� <br /> ( � I // O0F,61�GNATED FACILII'YTO GENERATOR <br />