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i <br /> Q <br /> UNIFORMyHAZARDOUSg1.GaneratoriDNmber p }tyP ) 2.Pagoiof'3, mergeneyResponsePhono 4,ManifestTrackingNumber ( °050.0039 <br /> Ple sn rirt oft e. Form.desi ned for use on el le 12 itch�����r. �� � J < 7 k ! � 1?" FormApproved,OP16 No.'s/, <br /> I(� <br /> WASTE MANIFEST I !<, r f)l=1s"r a"� f 1--:'x00 46, �i� 0 SKS <br /> 5,Goneratoes Name and Mailing Addr ss Goneratoes Site Address(it different Than mailing address) <br /> l co Air* <br /> �+9;r:lisaps. 1i7 ' <br /> $ACRAy1EINTt3 <br /> GonetAor's Phone: III _:f.&A <br /> 6.Transporter 1 Company Name U,S.EPA iD"Number <br /> ;yAF±r'Y--Kl,t»EN PiY 1EM8 1!Nj C <br /> 7.Transporter 2 Company Name � U,S,EPA ID Number <br /> CLEAN HARBORS £:NUIRONNQNTAL "a;!PUl:,'c::s .rNc <br /> 8.Designated Facility Name and Site Address }�j l�..�r /`� HARBORS <br /> R U.S.EPA ID Number <br /> r Iwo <br /> Faciilly'a Phone: 408--44l' r3' 1 ' el J1,8E tS <br /> go 9b.U.S.:DOT Description(including Proper Ship ingName,Hazard Class,ID Number, 10.Conta'ners it.Total 12.Unit 13.Waste Codes <br /> Hd and Packing Group(if any)) No. Type Quantity Wt.rVoi, <br /> —T— <br /> CeINV3N IRG RA F#-1 1f,TD'il S 14,A ATE SUL TT)aI -. WI <br /> l (41u 41s, P I r O( E{ E 11 <br /> i 2 <br /> w I <br /> t <br /> 3. <br /> 4. i <br /> 14.Special Handling Instructions and Additional Info mats n <br /> TSI} S J s 1.37 3 C <br /> 15. Wl�-81210- <br /> JdENEOfbR'SIMPE-909'8CVFZt(FICATiyderldiell1rut 0dril9rd f Id m ntSr• r antl Y r 1 p 3 s db` I Ite p�8 e w i ping name,and ate classified,packaged, <br /> marked and labeled/placarded,and are in all rdspec s in proper condition for transport according to applicable Inlemationalond national governmental regulations.If export shipment and l am the Primary, <br /> Exporter,I certify that the contents of this cons! nmeppIconformlo the terms of.lhe,attachad EPA AcknowledgmentofCorisehl. <br /> I codify that the waste minimization statement 1 ealifjed in 40 CFR 262.27(a)(if I am alarge quantity genecaW!or(b)(ill an a smrdl quant! .generator)1,0411 <br /> one slQeror's Pinto Name S'grrd Month Day} Year <br /> T-T. <br /> J 16.InternQtionalShipments <br /> ❑Import 90 18,( �Expad from U.S. orf of onlrylexil: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporterAcknowfedgmantofReceiptormated a - f <br /> Transpado PdntediTyped Name Signat reg Monih Day -Year <br /> CL <br /> y <br /> Z Tran tin d ame <br /> sign e ura M nth Day Year <br /> 18.Discrepancy - <br /> 18a.Discrepancy Indication Space quant ty ❑Type El Residue ❑Partial Rejection tJ FiroRejection <br /> i <br /> Manifest Referenda Number: <br /> 78b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> � I <br /> c.5 Iud Facility's Phone: <br /> w 18c,Signature ofAllornale Facility(or Generator) Month Day Year <br /> F— <br /> N19.Hazardous Waste Report Management Method Rodes(I.o.,codes for hazardous waste treatment,disposal„and recycling systems) <br /> 4. <br /> 20.Designated Fac00wne�rird'perator.Cerilgcal on okra ipt ofhazardous materials, erad:by the manifest oxcap as ndod in Item 18 f,. . <br /> Pante rrypej Name r, ' Signer ” l i` Moot�i_ Day Year <br /> EPA Form 8700-22(Rev.3 05) Prevlaus edition re o�solet J/ ,� Ut$IGNATEn FAC(l-1TY TO GENERATOR <br /> , F , l, <br />