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•� is a3S �itlw'it ,;i1a ;�r �,=.. <br /> Please print or t pe (Form-designed for Use oil°elite 1.2 ilnh <br /> w PP <br /> 1IF iHANIFB9T p )rypewriler,) Form Approved,OMB No.2050-oo30 <br /> * UNItaC1t HAZA} OUS f�urnb r r <br /> 2,Ps of 3. mar ency Response Phone 4.Manifest Trackin Number <br /> rGBnerator tb i"P�f_ C'tk 183u 1._�t> �'i ta"t3'—1760 )04858" <br /> (� <br /> 5.Generalnr s Name arid Mailing Address 0 8, ". SKS <br /> Cisco Ail" S;/M e d i I rti� Generator's Silo Addresa(i f different than mailing address) <br /> 14 27th St <br /> ; L til >~NTt <br /> `�1�+"'�}�}E}wi~Jc�.t:i Ca 95816—mol R E C�E I V E O DEC D 5 2,016 <br /> Generator'gPhone; <br /> 6.Tran porter 1 con)p Name <br /> SAI SYSTENSIj NC, U:S.EPAIDNumber — <br /> •1`XA�uu�M 120,5 <br /> 7.Transporter 2 CompanyName <br /> . U.S.EPA ID Number J `� <br /> 8.Desgnaled Facility Name and Silo Address __ eio <br /> C E-AN- HARBO *S ARAGONITE LU U.S.EPAIDNumber <br /> NORTH APTU PC)A 1 <br /> AGONITE <br /> UT 84029 <br /> Facility's Phone; U'TI}r8 a 552177 <br /> ga, W U.S.DOT Description(including ProperiShip Ing Name Ha;at <br /> HM and Packing Group(if any)) q q,lass,ID Number,._ 10.Containers 11.Total 12.Unit <br /> > No: TXPe Cuanlity WL13.Waste Codes <br /> NoI, i <br /> Q 1 4!ifi3C# NON Ri.:RA HAV D1�l,IS WAST L 10-I13I13%. DM <br /> P L41 <br /> Uj <br /> c� <br /> 3. <br /> 4. 1 <br /> 14,Special Handling Instructions an Addilwnai lnformalio �^ <br /> 7 13: f�G C13,3793 ta, <br /> 24 HR 1760 (Sit ! 7' E <br /> S AS <br /> T t <br /> GENERATOR'SIOFFEROR'SGERTIFICATION 1hrebydeclare that lhec,MDots.&this corisignmentaratupyandaccuratelydase»bed`abovaby:(hoprapershppingname;aMaraclassi�ed,paGkaged,� <br /> gporl;and lapelad/placardsd,and Ore in a0 too pool in proper condition for'transport eccordfng to applicable lnlsrooponeland national governmeniai[agutabons:If export shipment andl am ed,P ma <br /> Exporter,I certify chat the contonts of this conslgnma t canformlathe;termo of attached EPAAgknowietlgmerit of Gonssnt ry w " <br /> i certify that the waste minfmizaifon stetomerit ld� lllli d in 40 CFR 282.27(2)(IP i am a large quantity generator)or(b)(tf i am sma!(y�uanUty,eneralor)is e. <br /> e ra r s10 ors PriniedlTyped N a <br /> Sign Month Day Year <br /> -_r 16.Intomatlo'ol:Shipments (� <br /> J <br /> p' Import to U,S. ❑Export from vs, P' of eniry/axil: <br /> Transportersignaturo(for exp rtsamw! <br /> 17.TransporlerAcknoMedgment of Recelpt of Matorlal Dole leaving U.S,: <br /> 0 Transpo 1 Por)ted/1Yped Name <br /> .Signal � Morilh Day Year <br /> Transpo s, rime. od <br /> Signa to Month Day Year <br /> {::✓' mit., 1r ': .7 ,f i <br /> 18a,Disgrepagy.indj'tion SpaCo tt--� �-•-} r t <br /> quantity '' QTypo . ' !_1:ftesido <br /> LJ RadIal:Rejeciion (�Full Rejection! <br /> L-:l8b.Alternate Facility(orGenerator) ManitestRaterenceNumber: <br /> 0 <br /> U.3..EPA iD Number <br /> rdi Facility's Phone: <br /> 180,51gnaluraofNfemateFaci6ty orGsnerabfj <br /> ------------- <br /> Month Day Year <br /> CD <br /> 19.Hazardous Waste Report Management Method Codes(i: .,codas for hazardous waste treatment disposal;and recydIng systems) <br /> 1 1• 2 <br /> 20 Designate.Facility Owner qr Operator,Certifioadgn;of re erpt of hazardous mile' <br /> ais covered by the memfasl except asndediti Item:l8a s V t <br /> Pnnto ypad Name Signature <br /> i Month Day Year <br /> EPA Form 870 -2 (Rev.3-05_Pr ions adilions ore bbs(lele. <br /> !)78- 3. <br /> 1:.31 �t~ DESIGNATED FACILITY TO GEN Fi 1OR <br />