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'C'"1 IAT5 A4 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) F=ANo.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator 11)Number 2.Pagg 1 of, 31 Eqprp�Fy,l a �ep% ManiksLIL N be <br /> SKSWASTE MANIFEST <br /> 5.Generators.Name and Mailin Address I I th fdret <br /> ?M-p�tle "A REG;; <br /> il —47 9 <br /> CA T5 .165 <br /> Generator's Phone: nrl 2 4 2016 <br /> U.S.EPA ID Number <br /> 6.Txaps <br /> pRr <br /> -teF,4-C Tqy Vaj4e 1,,t:iv,, <br /> 7.Transporter 2 Company Name ENVIRONMENIAr MMMWIDMmber <br /> DEPARTMEN[T <br /> 8.Designated Facility Name and Site Address GLEAN HARBORS MER TRAIL LA-11' U.S.EPA ID Number <br /> M5155 F HIGINWAY 136 <br /> rJUP TRAIL a) nivn <br /> Facility's Phone: J COOK%'1-30 04 6 4 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> WAE <br /> R AZARDOUS I'VE ii.%,; <br /> 0 11" SL.LiWt',� 14NII PWI <br /> oil <br /> X 2. <br /> LLI <br /> 3. <br /> c <br /> 4. <br /> D R <br /> 14.Special Handling Instructions and Additional Information S,D '10, 3f. F',': <br /> PA HR F-MFRGF.Nr,'Y :#1--800-- If"A-1760 tU IM <br /> -.r rIP 11 Viy 9f'.,"N TO RU'Pl I N rFtf�;F_P S�JB CAIRJ-,�.I US rlz-li R� <br /> 15. GENERATOR'SlOFFEROR'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, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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 small qua%j;W0RWtqajb4&= <br /> Generatoes/Offeroes Pdntedrryped Name Signature Month Day y <br /> !,JAI 1 ^7. <br /> :-j 16.International Sbiphients <br /> li- 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ?= Transporter signature(for exports only): Date leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> Li <br /> Transporter 1 Printed/Typed Name Signature Month Da Y <br /> 0 <br /> IL <br /> Z /Typed Name Signature Month Day Year <br /> Q <br /> W <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space [:1 Quantity El Type ❑Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL Facility's Phone: <br /> W18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> a <br /> u, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI 1 2. 3. 4. <br /> C11 I 1 1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pr (Typed Name Signature Month Day Year <br /> EPA Form 870.0-22,(Re.y.-3-05),Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />