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�< sm.SHIP* <br /> Please print or tYpe{Form designed for use on elite(12-pitch)typewriter.) <br /> t.Generator ID Number », Form Approved.OMB No.2050-0039 <br /> UNIFO HAZARDOUS 2.Pa e 1 of 3.Emer ency Response Phone 4.Manifest Tracking Number <br /> W E`MANIFEST F$L 7 'mI 1760 <br /> SKS <br /> \/ <br /> enerato?s Name and Mailing Address Generator s Site Address(if different than mailing Rr§13 <br /> ) <br /> > —,-Golden Baty ADESA � �� ��a t� <br /> 2 I 5 d Rd Atte¢ � 1 � n�9y 1 t�nf e^d Rd <br /> TR '� �� 77 ttn fetygall <br /> Generators Phone: � m TRACY GA 9 �- 7 <br /> Sam <br /> 6.Transporter 1 Company Name <br /> SA <br /> LEEN SVSTEftINC U.S.EPA ID Number <br /> TXA I� <br /> 7.Transporter 2 Company Name <br /> CLEAN R V I RC1 TTL, SVC INC. U.S.EPA ID Number <br /> B.Designated Facility Nar�e and,SiteAddress - MAD03932 <br /> _. _ ._w U S;EPA ID Numbery - <br /> MILES AST9 7 MIL, NORTH ROLL EXIT 19 OFF I— <br /> FacilityKNOLLSUT 04093sPhone: <br /> UTD99130,1748 <br /> a <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,.ID Number, <br /> HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit <br /> No. Type Quantity 11 13.Waste Codes <br /> 'NON RCRA HAZARDOUS WASTE SOLIDSV (USD _ <br /> OIL ANS S'ORR NTS) ISN 332 <br /> 2 2. <br /> •; W <br /> CD <br /> 3: <br /> 4. <br /> 14.Special Handling Instructions and Additional information <br /> TMON 74266556 I9 <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,erd are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental reprop r ship export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenI of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if i am a smoll,quantity geperator)is true. <br /> Generator's/Offeroes Printed/Typed Name Signature <br /> Month Day. Year <br /> .1/ A --/ All � V ( � <br /> -r 16 International Shipments I ¢ , <br /> r:=. . F r < ❑Impott <br /> Z Transporter signature(for exports only) ❑Export frorti U S.' Port of enkry/exit <br /> ' Date leaving U 5 ' <br /> 9"7ransporerACknowledgment of Receipt of Materials ` <br /> Mi Transporter i1 Printed/Typed Name' '• . <br /> p Signature <br /> I1y� �� s: � �nt�l���D���.� <br /> T,an 'pet2P ignatutearK <br /> ancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Ty ❑Residue. ❑Partial Rejection ❑ <br /> FuII Rejection <br /> Manifest Reference Number: <br /> 1 <br /> 113b.Alterna:Facility(or Generator) U.S.EPA ID Number <br /> w Facility's ph <br /> )Sc SignaurpofAitemateFaGilit {Qr,Geetafgr); ,Fr <br /> :�...:.. <Month Day <br /> as 19.Hazard s Waste Report Manag <br /> Z <br /> ement Method Codes(i.e.,codes for Hazardous waste treatment_disposal;and recycling systeLLIms) i <br /> 4. <br /> 20.Qe igna ed Facility wner or Operator:Certification of receipt of hazardous materials covered by the manif t <br /> am except as n ed i Item 18a <br /> i Print y d <br /> Sign e <br /> { <br /> PA Form 8700-22,(R,v 05) Previous editions a e obsolete. _ <br /> ,e DESIGNATEb'FACILITYTO GENERAT R <br /> i <br />