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!" Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) am I IIII III III I I I I 111111111111111111111 Form Approved, OMB No. 2050-0039 Nftwoo� EPA Form 870x22 (Rev. 3.05) Previous editions are obsolete. 4 DESIGNATED FACILITY T06FT UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Trackin Number WASTE MANIFEST -00 -;-- 008680793 FLE C ,r;;,.,•_=4. 1 V1� /A 5..4a, Generators Name and Mailing Address Generators Site ddress if different than maling address) t#1F:'lti� ;_>Z9 8D 350*a` J }.Is1+F4 4 T V 4TIji.,v I qtr klgay. )wtite G I 4cf'4 r rril;;y Par' r.};;..fir. Generators Phone: C3 or t a te' `�`� Stockt0i)4 CA l 6. Transporter 1 Company Name U.S. EPA ID Number Stevie' ie SPecialty Wa=tE 04(tci.01-14: of 0 `1 _tr:cititaS`<ro&? ( 1. Transporter 2 Company Name U.S. EPA ID Number U.S. EPA ID Number 8. Designated FacilityName and Site Address .rn:arnt; __i 185 t;itC R 0 C k Frnad G ?f1Crl� )uor dovaj CA 9574'r_' Facility's Phone: i t;,..�; �. vl'? i;H''otirttfih +.i. r} J wwwo 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity WI.NoI. 13. Waste Codes No, Type 'X 1'Uwal.:*; ia54ce TOxiC, 50tr'ganic; n. D. s. :. (i= ILI00t%r_ C, :3'(i DOO? nvli;ii ' ]01 l.rttttr �P1E iUffiJ) rJ, Nt _: f. r�tt7#7.54 Z 2. W f7 3. MMMMM 4, APR 01. 14. Special Handling Instructions and Add tional Information TAL HEALTH DEPARTMENT 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, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable inte and national governmental regulations. If export shipment and I am the Primary Vonal Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAclmowledg VYant. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity genera! )m a small quantJV,,qeAeretK is true. Generator ero Pnnted/T ed Nampa Month Day Year 4 Zi 6. International Shipments ❑ ❑ F- Import to U.S. Export from U.S. Port of entry/exit: Transporter signature for exports only): Date leaving U.S,: W 17. TransporterAckno ledgmentofReceiptofMaterials Ea' Transporter 1 Pdnted/Typed Name Sign ur Monthay Year a i_' I =r l i= li tq - - = Z Transporter 2 Printed[Typed Name ignature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space El Quantity El Type El Residue El El Partial Rejection Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID Number J U Q LLd Facility's Phone: C3 MANNE 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z wows 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) C 1. 2, 3, 4. 20. Design ed Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as n led i m 18a Print ed Na Signatu Month Day it As'e q 1 P & ( 'a" �� 46Z 4? 0 1 N INATION STATE (IF REQUIRED)