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Form Approved. OMB No. 2050-0039 - 4 GENERATOR i ,..... <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />CACCO .g..0'7 cl'3 ZA <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />goo 112(11(31. <br />4. Manifest Tracking Number <br />021913507 JJK <br />Generator's Islame and Mailing Acklress Generator's Site Address (if different than mailing address) we,„&e,i. ente,,,prtc-C,5 k (Nc.,•• 6".fejtprs/5-e...c <br />I 9 go -7 Fro A 1-4 e../ 1 e f 3-7 •02 1 -rzt - yy 7s <br />0 Poi A 4-14.1 r ve I, g 1 3 g Tr.tt -1 CA <br />Generator's Phone: I <br />Transporter 1 Company Name U.S. EPA ID Number <br />po lf$01- eAtIJN(“AieivEct,( 5 .6.0 i Ce S I cADos3 g c, 6 7.-pq <br />Transporter 2 Company Name U.S. EPA ID Number <br />I <br />Designated Facility Name anq Site Address, U.S. EPA ID Number <br />crosby d oveflo" It 3 , w. I/ 4A,, 5 ..f.. 1.0 A 1 (3. C., dm CA <br />C A 0 o 2 eq0,v0)ef <br />Facility's Phone: go. 11.1 (012 9 1 <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes <br />FHA and Packing Group (if any)) I,' No. •i Type Quantity Wt.Nol. <br />1. PCR & f-Inz A r ot06^-57 v•teff-e, 5,0 Li 0 1 u PMLio.t, p 352 <br />rioN <br />sdeboes ci, D les.e.f <br />2. <br />....... 1,. <br />... <br />t.• <br />3. <br />- <br />4, _ay.' <br />IF . ' <br />Special Handlip Instrupo ns and Additional Information A. c5e_ ro ef pp <br />3v fo -It osi 3 _ zo - 0 0 (401 , , . .... . , Dj tiS5 0 <br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignDent are fully and accurately described above by the proper shipping name, a 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 contOrm to the terms ethe attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 49 CFR 262.2(a) (if I am a large quantity generator) or (b) (ill am a small quantity generator) Is true. <br />Generator's/Offer* Nnted/Typed Nablehsip Signature Month DaL Year <br />Oa ileiv•-/rof .4.c),€-( rice S I <br />_1 <br />r- <br />.g <br />International Shipments LII Export from U.S. Port of entry/exit Import to U.S. <br />Transporter signature (for exports only): Date leaving U.S.: <br />j:. Transporter Acknowledgment of Receipt of Materials IRANSPORTE Transporter1 Printed/Typed Name Signature Month Day Year <br />if5v) Awl 64,0 1 k.._,,(011------ 1 <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I I 14-- DESIGNATED FACILITY ----0- 1 Discrepancy <br />tity Residue Partial Rejection E Full Rejection 18a. Discrepancy Indication Space Quan Li Type <br />Manifest Reference Number: <br />1 8b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />1. Lii <br />2. 3. 4. <br />20. Designated Facility Owner or perator: Certifica ion of receip f hazardous materials covered by the manifest except as ncred in Item 1a <br />Printed/TypedNam t AU t.. <br />Os-1..V---- <br />Signature \.........„.„.../... <br />) <br />I Mont Day <br />I 21.17--6 <br />e A nil rrkr -rri en A Pe. rk RA A 11.11CGOT CVCTC1111 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.