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1111111 l li i 111 l 111111 lli 11 1111 l 11 l lII <br /> 0072755063 Ks <br /> Please print or type. Form Approved.OMB No 2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone_ 4.Ma1067275806 <br /> tritest Tracking Number c e�(e <br /> WASTE MANIFEST O 7 2 7 5 S O U V„V <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> -r—hiS, ING. <br /> Generator's Phone: ':"q--545-1@1 1 <br /> 6 Trgnspgrlgr 1.Company Name ,Y�,,,.�� rNC U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 1C, <br /> 8.Designated Facility Name and Site Address -•HERM0 FLUIDS INC U.S.EPAIDNumber <br /> 12533 SE CARPENTER DP <br /> C[. lC1 AIWF "7P15•-8388 <br /> Facility's Phone: 503-788-4616 <br /> ga 9b.U.S.DOTDescription(including Proper Shipping Name,Hazard Class,ID Number, 1g.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt Ivol. <br /> 1. ?A HAZARDOUS WASTE 501 I 2rJ� <br /> o =IJIl1NDRCsii+lEll USED bbl Ill =- <br /> w <br /> Z 2. <br /> W <br /> U <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TC-1-1,q-FCJ e;A1_ C. <br /> H EM�R6EhdI V 86Q1-4F8 17EQi—EiI;Ru/TFI—CO'1tr�rt I-PtAined r'f)nfara aygn y arrt h0 <br /> 15. GENERATOR'SIOFFEROR'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 iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and natbnai governmental regulations,If expon 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 minimizaffon statement identified in 40 CFR 262.27(a)(S I am a large quant ry generator or(b)(if I am a small quantity generator)is true <br /> General 's10ft o PdntedlTyped N Signatu Month Day nYear <br /> e5 � C( <br /> j 16.Inte national Shipments <br /> r ❑Impart to U.S. ❑Export from .S. Port of entrylexit <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17 Transpo4ar Acknowledgmentof Receiptof Matenals <br /> lTransp er 1 In dRyped Name Signatu Month Day Year <br /> a v Z D <br /> rn Jaw4al it Name Sig Month D y Year <br /> 18.Discrepancy <br /> Ito Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone. <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N1g.Hazardous Waste Report Management Metilod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2, 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receip€of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 6700-22(Rev 12-171 Previous editions are obsolete. DESI@NATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> OR14472_WT_007275806SKS 15 <br />