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PleaAa print or type,(Form designed for use on eilte ?-pitch)typewriter.}
<br /> Form Approved.OMB No,2060.0039
<br /> UN(I`0RM HAZARDOUS 1.Generator 101011bal yllaga I of Emergency Response Phone 4.Manifest raAnP No ibar,
<br /> 060 SKS
<br /> C A L 0 0 1 Xt C*)(A
<br /> WASTE MANIFEST k
<br /> 5.Generator's Name and Mailing Addres's is Address(if different than Melling address)
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<br /> CA
<br /> Generator's Phone: of P
<br /> 1-3 � I Ono
<br /> 6.Transporter 1 Company Name —U.S..Emu Numoer
<br /> s we 6-,i\j SYS rEW3 I I C
<br /> 7.Transponer 2 Company Name
<br /> U.S,EPA ID Number
<br /> B.Designated Facility Name and Site Address 1,1 IF I I N I I A 111 OR 1,� PkI Y X r,0 N 11*31 T A L. U.S.EPA ID Number
<br /> 2'247 8 H"GHWAY 'i
<br /> VILL INE 69,145�
<br /> Facility's Phone: 308- -401 t~ i M-D)913 I 7a,3!5
<br /> 9a. 9b.U.S,DOT Description(Including Proper Ship i Ing Name,Hazard Class,ID Number, 10,Centeiners 1t.Total 12,Unit
<br /> HM and Packing Group(it any)) 43,Waste codes
<br /> • No, Type Quantity, wt.Nol,
<br /> 0 NON RCRA HAZARDOUS 14A.10TE LJOUTBS VIM P 141
<br /> ('31ARBON) 4 wq,�,
<br /> Z 2,
<br /> 3.
<br /> 4.
<br /> 14.Special Handling Instructions andAddillohal Infomiatien
<br /> T61) VY X 27202 140,
<br /> *V #1 .,
<br /> 811110 Z 18-17E0 (CH I SK TFI)
<br /> --A"I"'CrIbb4fibod P6��;ptd I R name,and are classified,packaged,
<br /> AO bENtIFICAMM M-re' a nh
<br /> 14P(dNEffiR1Sf0`FPtfid' 'by n 1;14191r,�121 N152-0:1PI'alety
<br /> marked and labeled/placarded,and are In all re pact in proper condition(or transport according to applicable international and national govern nWlregulaffons.11 export shipment and I am the Primary
<br /> Exporter,I certify that the contents of(his consignme t conform to the terms of the attached EPAAcknowledgment of Consent,
<br /> edifyat he wastemInimizallon slatementldantill.din 40 CFR 262.27(a)(if l amalmlisquantity lleri5op}or(b)(III small quantityr"t
<br /> 4 arater)f/1-0.
<br /> ane(alrod rs-11 erors PrintocIrryfied ame St nplur Mot Day Ye❑
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<br /> I B.International Shipments Import to L.S. D Export tram U.S. Po d of entry/exit:
<br /> 411j�
<br /> Transporter signature(for exports only); -11--1671peaving U,8,:
<br /> 17.TransporterAcknowledgment ofRecelptof Malerials
<br /> �2 Transpow Printadflyped Name Sign late Month Day Year
<br /> 0 1 1 Ale)
<br /> 2--
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<br /> T hsppff2'PrFnI8dfTyp am-6 r t ign lord
<br /> W.) nth. .�o. by Year
<br /> 'u-1—It",
<br /> Mbliorepancy 7
<br /> 18a.Discrepancy Indication Space ou.,lit, ❑TypeEJ Residue 0 P,,I,l Rilio,tion El Full Rejection
<br /> Manifest Reference Number-
<br /> 18b.Alternate Facility(or Generator) UIS,EPA ID Number
<br /> U
<br /> L11 Facility's Phone: V
<br /> 18c.Signature ofAl(ernalo Facility(or Generator)
<br /> Month Day Year
<br /> 1j,Hazardous Waste Report Management Method Cb as(�.o,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 12 13, 4.
<br /> 1��Iily Owner or Operator:cortificallo,of rcelpt of hazardous materials covered by the Manifest except As noted In Ilem 18a
<br /> Signature Month Day Year.
<br /> EPA Form 8700-22(Rev,3.05)N6066js edits ns 1616. DES16NATED FACILITY 7.0 6-f--NERATOR
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