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Pie se prin't Cr type.(corm designed for use on elite(12 pitch)typewriter,) Form Approved.OlVIB No.205P.0039or
<br /> i,Generator lu Number Page I of 3.Emdrgency Response Phone 4.11 ah lost VaMfltulnu
<br /> 7 b-1 0 0 5.
<br /> UNIFORM HAZARDOUS 000-4613-1, 86, SKS
<br /> I,f A 1 0 0 iA 1'4 6 �Ifil 0 85 4
<br /> WASTE MANIFEST
<br /> KGonerotoes Nome and MallingAddress Generators Site Address,(if diflerant than mailing address)
<br /> - - I
<br /> (;n'NS
<br /> ('PnPrn1neq Phone, 6—'A Fl U,S.EPA ID Number
<br /> 6,Transporter I Company Name
<br /> U.S,EPA ID Number
<br /> 7,Transporter 2 Company Name
<br /> CLEAN HAKFORIS EIVIRON: SX1181 ING
<br /> I U,S.EPA ID Number
<br /> 8.Designated Facility Name and Site Address T*11 HAMAORS 0CM JUSil:
<br /> 't PWORyns"m 13ow)
<br /> J C�19 1"'
<br /> -4 f4 I-QT:1S,.,?
<br /> Facility's Phone: —:-
<br /> 9b,U.S.DOT Description(Including Proper Shipp ng Name,Hazard Class,10 Number, 10,Containers 111.Total 12,Unit u.Waste Codes
<br /> 98. Quantity wtivol.
<br /> HM and packing Group(if any)) No. 'type
<br /> 0
<br /> Z
<br /> LU
<br /> 0
<br /> 3.
<br /> 4,
<br /> 14.Specai Handling Instruc8onsandAddiional in ormall C3 13793
<br /> 2-4 HPit r,i (OK I TF1
<br /> ally an acou a a ydescribe
<br /> 1 ping mime,and are classified,packaged,
<br /> re 3 ropoi
<br /> J§,-,,�-dddu ale
<br /> 'SCE FIC ON: odec re 126hintaf fff,
<br /> "per condition for transport according to applicable International and national governmental regulations,If expoA.'ghlpment and I eni,the Primary,
<br /> marked and labeled/placarded,and are In all r spe I pro
<br /> softht)aftachedEPAAcknoy4edgmentofConsOnt,
<br /> I codify that 11 Ity generator)or(b)(fit am a small quantity generator)Is true.
<br /> Exporter, �Ig n m nt conform to the term 61-1
<br /> nt Iderill ed I n 40 CFR 202.27(a)(Iff am alargo quant!
<br /> I corilly that the waste minimization statem, ont ola'T 'j,�;,Year
<br /> -
<br /> ,G6neratoesio0atoe5Pdnted[TypedName
<br /> t7`
<br /> -j 16,International Shipments ❑Export from U;-S, 1 Pod of on"lexit:
<br /> D Import to,U.S.
<br /> Transporter signature(for exports only); Date leaving U.S.;
<br /> 17.TransporterAcknoviledgment of Receipt of Materials Month Day I Year
<br /> fe
<br /> Transpo qr I Printed/Typed,Name
<br /> �',1. 11 1�,-- Signet*a o�t,
<br /> CL eleconih Day Year_
<br /> Tran o—j"21 antearTyped Name
<br /> ----------------
<br /> 18,Discrepancy ❑
<br /> ❑Residue P.N,l Rejection FS Rlejetlion-
<br /> 18a.Discrepancy indication Space El quantity El Type
<br /> Manifest Reference Number
<br /> U.S.EPA ID Number
<br /> 18b.Alternate Facility{or Generator)
<br /> 61'. Facility's Phone: Month Day; Year
<br /> 0 -1-8v,'Si9rotwo o7lwnale Facility(01 G..rotor)
<br /> LU
<br /> (D 19.Hazardous VVostoRl is(Le,,cod us waste treatment,disposal,and recycling systems)
<br /> as for haz6rdo
<br /> 3. 4.
<br /> of hazardous materials covered by the manifest except as noted In Item 1111a
<br /> 20,19.Hazardous
<br /> Facility'Owner or Operator:CarOR0110A if receiptMonth Day ear
<br /> Signature
<br /> Pfinted[Typed area
<br /> EPA Form 8700-22(Rev.3-05) previous editions are obsolete,
<br /> GENERATOR'S INITIAL.COPY
<br /> 7 41
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