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qr)t s {I 't1 0'34433S81 <br /> Please print or tyna IForm designed for.use oneilte.('1�7-pitch)typoviiiler.) Form Approvep.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.GeneratorlD NOmbei 2.P=Emergencypon,d'Pliona A.Manifest TrackingNumbsrrWASTE MANIFEST C�1f..�+o1/SFs 57 ,01 t7 4� <br /> 5.Generator's Name And Mailing Address Genoralors Site Address(if different than addroq) <br /> i..7.5C2 G )t�.i Y. S',i St e if U I rt <br /> 2114 9St <br /> .01 <br /> Generators Phone. J. a r , , a WA <br /> 8.Transporter 1 Company Name ID bar <br /> 'i'KR��i�T�%t�1�?k}:, <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> I:!,•EAN HAF?BOVS I NV I RO!1 IT NTAL. SIX INC, <br /> 8.Designated Facility Name and Site Address U.S,.EPA ID Number <br /> CLEAN HARS.OPS SAN JUSS <br /> 1 I tI,RRYFSSA ROAD <br /> itr�s ,u•+Ml_4t ,M, jf)Rt �a �(M <br /> Facility's Phone; <br /> Sa, 9b.U.S.DOT Description(Including Proper5hip ing Name,Hazard Class,ID Number, 10.Containers 11.Total 12:Unit <br /> HM and Packing Group(if any)) No. Type <br /> Quantity Wt./Vol, 131 Waste Codes <br /> 1. t� I <br /> ttit;;IRSA HA"A "JOI_IS WrI n r St l_]I) •i Wit <br /> w <br /> 2 �i <br /> i <br /> 3. " <br /> a. <br /> 14,Special Handling Instructions and AdditionaLlnformati n <br /> 74794565 Q 13 37 <br /> r�34�1 <br /> 1.`jGFNE" TQR`5 tYF ERt� ' 'C� FICAT r: er y de re( at tti nt IS cdn`si�IS nt§r a d k� ba �boV'b)sil�epltr+s i ping name,.and are classired,peckagIad, <br /> marked and labeled/placarded,and are in all raspec a in proper.condition for transport according to applicably iriternalional and national governmental regulations,if export shipment and i am the Primary <br /> E>pbder,t cedlfy thatihe contents of this cdmslghm nkconfon4 to.the ferias of the attached EPAAcknowtedgmento(Consent•' <br /> I certify that'tho.waste mtnimizelion siatemont"i'denti ed in dO CFR 262.27(a).(if I am a large qunngty�en�dr @)(ifi a a small quantitygeherator "he. <br /> LZ <br /> �arh9rslOff LorsPrintedfrypodName Sign re �Mon1h Day. 'I, Year <br /> i ! <br /> 71 <br /> r i8.inter ailonai pmenls ' <br /> j p✓ Import to IU.S. ❑aport from .S. Port of anirylaxii; <br /> Z Transporter signature(for expol only): Date leaving U.S,: <br /> 17.Transporter Acknowledgment of Receipt of Matadi$ <br /> Transporter dnted1Typed Name Signa �, Month Day Year <br /> g �� Sin r �+ ori y Yaar <br /> QTrans e. do d d a r .' r+ <br /> od <br /> 18,Discrepancy ll <br /> i8a.DiscrepancyIndicallm'Space Quantity l_IType ❑Residue +�IPartialRejection FuIlRejeclfon <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) w ti U.S.EPA ID Number <br /> w Facility's Phone;- <br /> w 18c.Signature of Alternale Facility(or Gene(ytor) Month Day Year <br /> a <br /> Z <br /> 1g.Hazardous Waste Report Management Method ode (Le„codes for hazardous waste treatment,disposal,and recycling systems) <br /> a t. <br /> 20.Designated Facility Owner or Operator:Cedification o receipt of hazardous materials covered by the manifest pt as noted in Item lea _ <br /> Prinledlr tjam Signatu ^�.�� oath D Y <br /> r <br /> EPA Form 4700 22(Rev.3.0 )Previous editions a e 6 solete. DIW iG J Ef FACILITY TO t i Edi #�A'CO» <br />