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1 <br /> Pl01 <br /> ease print ortype, <br /> I.Generator ID Number Fora APProved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page i of 3.EmergencyRespense Phone 4.ManHestTracking Number <br /> WASTE MANIFEST �n1 113120791 F L E <br /> .,r•1L1,�1?I�4,'�7Ei r.i7 � �l l-!l.r..=a :G <br /> 5.Generators Name and Mailing Address Generators Sita Address(f different than mailing address) <br /> 1i1t:i ti;��; -,:_I`%i:S ].'�rlth <br /> ? -.l'': <br /> r t:..i.r_12,>f OLJi� rrtll}. !" 1 ;_ <br /> ►_..:)121 ii){-1CTF.'i 1 (--I <br /> Generalors Phone: i nom~}; 1)T3 C;ri rah'' " <br /> 6.Transporter 1 Company Name { �` 1 r - �tA <br /> U.S. <br /> :')ASfEPA ID Number <br /> :- .`irillll;lur'� l.P1C <br /> 7.Transporter 2 Comparry Name 1\1Q fi11' hI M CI-�i <br /> - U.S.EPA ID Number <br /> Rer_Over• r 5 <;'•:Llys <br /> B.Designated Fac lily Name and Site Address <br /> Yl!r13 Yes, L_L_t:' U.S.EPA ID Number <br /> 2`730 E. 9.311-h Str-eet <br /> ly i. SJ_S I:rJ <br /> Facility's Phone92864F'8938 <br /> ga. 90.U.S.OCT Desd0on(mduding Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(d any)) 10.Containers 11.Total 12.Unit <br /> hill ":''#;? , t No. Type Quantity 13.Waste Codes <br /> WLNot. <br /> 7Zti' i; ii•.tti is (Sozins. i X171.':?-7 :] <br /> 17.1 <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Specht Handling Instructions and Additienal Jnformafion <br /> 2. 12(71�fh '{r„_�tg (Zetil:lcl-;,'E1C i.-inch-itis? , <br /> 75. GENERATOR'SfOFFEROR'S CERTIFlCATIOI L I hereby C i zim that the contents of this cons[gnment are fully and acara ey described above the proper s'Pping name, are classified packaged <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to appl ratite[rdematiorel artd national Bove rttaf regulations.if e <br /> Exporter,I certify that the contents of this consignment conform to the terms of the atached EPA Acknowledgment of Con 0 export shipment and I am the Primary <br /> I certify[hat the waste minimization statomentidenfified in 40 CFR 262,27(a)(d I am a large quanfitygenerator)or(b)(it me 11 quan' gene r)is We. <br /> Gem aloeslOfferors Pdnted/Typ I Name SignaWre� <br /> a 1.f of Limit,a Morth Day Year <br /> -j 16.international Shipmen 06 2,5 _ <br /> ❑Import to U.S. ❑Export from U.S. Port trylex t <br /> Transporter signature(for exports only): <br /> W <br /> 17.Transporter Acknowledgment of Receipt of Materials l 'ng U.S.: <br /> 1-- Transporter 1 PrinledfTyped Name <br /> na e a <br /> any Month Day Year Iviaclt <br /> a Tran erg Pdnte yped Namp Sigma (A6 25 TON <br /> ?.5 <br /> CC ` I ]- Month Day Year <br /> 18,Discrepancy <br /> Ilia.Discrepancy indication Space ' <br /> ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> 180.Atte 1 wit:Facility(or Generator) Manifest Reference Number. <br /> "7 U.S.EPA ID Number <br /> V <br /> ri Facilitys Phone: <br /> Lu 18c.Signature of Alternate Facility(or Generator) <br /> Z INaNh Day Year <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Uee hit,dsposa�,and recycling systems) <br /> O 1 2. <br /> i ' 3 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials Cohered by the manifest except as noted in item Ilia <br /> Printed/Typed Nam <br /> /� � t Slgnatum Month Day Year <br /> EPA Form 8700-22(Rev.�t/2-17) Previous edilians are obsolete. <br /> •S PJA7ED}=AGILITY TO EPA's e•MANlFEST SYSTEM <br />