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Please orinl or lvoe. (Form desioned for use on elite (12 -Ditch) tvoewriler.) Form Acoroved. OMB No. 2050-0039 EPA Form 81UU-22 (Rev. a-Ub) Previous editions are obsolete. GENERATOR'S INITIAL COPY IFtf 4.9 ,1) i`.•JC�t )/4/1.'-iitsJi �ri UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number S KS WASTE MANIFEST 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) cik'1 or,,". (.ii Iii,f.,f.rtiiil {t �Tnr� � nrl GA 95203 --49 40 Generators Phone: 6. Transporter 1 Company Name U.S. EPA ID Number ti ci71.h1f.i it It{) IJ t�lll'itk'IVIEii 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address CLEAN HARBORS ARAUUoi l I i,y I-1 .L: U.S. EPA ID Number 11600 NORTH APTUS ROAD ARAGONITES , LIT E14029 Facility's Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity WI.Nol. � Uh'F'{I��:�k,` Id. U. ;:;�4-•_{•GIUf}.T..t�i�l.�i`l..l�L(3lVJ# Q ._. �•taht-,,:�).tf�ilry;-}; .._ r.--••-'r-rid--.7•X.�.__� W 0 2" .:. 1 t r1Ht(r1Eaf1L.L:. t. IOU I. Do" N> 11. 1=TfiYL III ! I S. ; f A1.1comi1_) , 3, Ps 3.. DISTiYFECTANTS L.IPIAD Il. B. (t�lJhit-RNARY AMMON10 J*,'0RR(J'2AVf N. , -- ' I COMPOUNDS), , E;, PG III 4. 14. Special Handling Instructions and Additional Information 917P17 ) ER13#153 2) ER(A1263) ERG #153.1 l HR F-MERGEN{:Y M -800-46A-1760 (SK 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, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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 small quantity generator) is true. Generator's/Offeroes Printed/Typed Name Signature Month Day Year /! fir''• "I - /f /(,fit (",1-r// ,"/I l r�.i�' /1 ! f r -r F- 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: K Transporter signature (for exports only): Date leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials l'- Transporter 1 Printed/Typed Name Signature Month Day Year O CL Q Transporter 2 Pdnledfryped Name Signature Month Day Year f- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑Type Residue Partial Rejection Full Rejection Manifest Reference Number: F- 181b. Alternate Facility (or Generator) U.S. EPA ID Number J U rai Facility's Phone: W 18c. Signature of Allernale Facility (or Generator) Month Day Year Q Z ,LD 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. 4. 20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/ryped Name Signature Month Day Year EPA Form 81UU-22 (Rev. a-Ub) Previous editions are obsolete. GENERATOR'S INITIAL COPY IFtf 4.9 ,1) i`.•JC�t )/4/1.'-iitsJi �ri