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Please print or type. Form Approved.RMB Na.2050-0039 <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2-Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Humber �/ <br /> WASTE MANIFEST L. 4.:t.t[1(1 : [.:i.fi.t f : AII-424-�7:aii>t { 1 `" J R <br /> 5.Generator's Name and Mailing AddrFA.0e{•1r�� 3� GeneraWs 3#e Address(tf different than malting address) <br /> Ci <br /> [ xwm Loner!;oa£f !{ a f?+75h f7r1 <br /> t;r+'x , f Fd J i fd06A - 4 Ri�usr}s c-'A Vk-t i+f! f j* A <br /> Generators Phone: C,G i-4:74 2 1,26 _ . . . <br /> &.Transporter 1 Company Name U.S.EPA 10 Number <br /> ^.�l�f•-q'ri� k{n.w!{:'�'.3rte�':pf'�9C-`t.'.�:�fE[.- - - �..�"4f':l��f�.���Z:� <br /> 7.Transporter Company Name U.&EPA ID Number <br /> 8,designated Facility Name and Site Address U.S.EPA ID Number <br /> Cry 01vertan,Inc. �-Ai7i}3ftirf�f}��e <br /> 1630 VV. 1 Zfl•r S. <br /> Facility's Phone: <br /> ga• 9b.U.S.DDT Description(Including Proper Shipping Name,Hazard Class,ID(dumber, 10.Containers 11.Total 12-Unit <br /> HM and Packing Group(lf any)} 13.Waste Codes <br /> No. Type Quantity Wl.Nai. <br /> 1.1{f t.f P4W- ART"- J�` 1AlA.S`f '8OA(f' L3fkl �' w1` <br /> 3. <br /> C <br /> 4.Special Handlfn tnstructlons and Addit onal Information <br /> �tr.1.Lilly t t >rr ,rbsarbent.Kazis,Dsbrrrs 6'rof ie 9 ot36U�) VV0--af ApiXopnste.Qotft{€W hesWator <br /> 40Z <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATION:I hereby dedars that the contents of this consignment are fully and accurately described above by the proper shipping name,ark are classified,packaged, <br /> marked and iaheledlplacarded,and are in all respects in proper condition for transport according to applicable interrationaland national governmental regulations.If export shipment and I am the Primary <br /> - Exporter,I certify that the contents of ttos consignment bonform to the ler roof the attached EPAAcknoip edgm&#4-Copsellr,__ <br /> I certify that the waste minimization statement identilled in 40 CFR 2132.27{a).(if I am a large gLanSty gerrerator]or(b)(if I am a s�rguanpty gerteratoo.is true. <br /> '"t-iem>.erau>rsl�11,pad Signatmna _ Month Day Year <br /> .Inte7TbShipments <br /> ❑Smport.ta U.S. ❑apottfrom u.s. Port of entrylexit <br /> Transporter signature{for exports only}: Date leaving U.S.: <br /> W17.Transporter AcknaMedgment of Receipt of Materials <br /> F` Transporter 1 PrintedfTyped Name It Signature t Month Day Year <br /> Transpor6er 2 rintedffyped Na Signa -+ ; ,. Morrth Day Year <br /> i- <br /> 18.Discrepancy <br /> 18a.❑iscrepsncy Indlcauan Space ❑ Q"* ❑Type ❑Residue ❑Parfial Rei,'f+an ❑Full Rejection <br /> Manifest Reference Number. <br /> Iax.Alternate Facility(or Generator) U-S-EPA ID Number <br /> [1 <br /> Faalilys Phone: <br /> 1Be.Signature ofA[ternato Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> e� 9.Hazardous Waste Report Management MeM Codes(€.e.,codes for hayardous waste treatment disposal,and recyeting systems) <br /> Ll ) q) 2- me3 4 7- <br /> 20. <br /> Designated Facllky Owner or Operator.Certifcatiort of race t of hazardous materials covered by the manifest except as noted In Item iiia <br /> Prints yped Name Signature .� Month Day Year <br /> EPA Form 6700.22 v.12-17) Previous editions are obsolete. _� TRANSPORTER COPY <br />