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Plea se print or type. , : - Form Approved.OMB No.2050-0039 <br /> 1 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone4.`m Cftl g, <br /> WASTE MANIFEST CALM367"2 2 1�SM255-3924 5 ' 430 GBF <br /> S.Generators Name and Mailing Address q,� ga; C flLT m ypt.,ff�-xaC�nar S Site Address if different man mailing address) <br /> (01 <br /> ) 2355 �. M Sam Y6GA III�LllVY9 <br /> Generators Phone:721-9739 MLA NO, QO 92215 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> BERN (M. M <br /> 7.Transporter 2 Company Name v OL MM acycYRra U.S.EPAIDNyat 0Wy2M7 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> BWERSPI/�yy q pq �+ ELL AdP/1pYt8�lV�o7p'1•�1C2�R LW. <br /> (051) MD 1B MViVd/A(z IM, <br /> Fadlilrs Phone: -% 0158 4"l <br /> So. 9b.U.S.DOT Desc6ption(including Proper Shipping Name,Hazard Cless,ID NTumber. — 10.Containers 11.Total 12.Unh <br /> HM and Packing Group if any)) NO, Type Quantity M7 <br /> 13.Waste Codes <br /> L q�e <br /> o ION-PLOA 1 Afpol s MTV 43DLED) LF+l1 P <br /> Mrk / u U � /SU <br /> Z z. o/t.-/ Pifc �i4r cRcs wr♦s <br /> UZSZ <br /> \ L J U <br /> F UGY 5- <br /> 3. <br /> 3. /.,�1 .c p, / 4-za,r�o�y s -®-- 35 <br /> i 4it/U✓ C/7 a Z,C ra acs C,) —5 e Fro rOR ?S <br /> ° <br /> 74.SPeoai Handling lnsbuctions and Addlfional Information —. <br /> MDRLFAq$I - I(MgLO <br /> -oy - �T I �gB� - tlasaa- o( -car 1 <br /> IME CMA RPROV0 SUETY RECAUMONs qac -l oo-i ;L& -rte- ar i <br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION: Ihereby dedam that the contents of this consignment are fully and accurately descrlhed above by the proper shipping name,and are classified,packaged, <br /> marked and labeled(placarded,and aro in all respects in proper condition for transport according to applicable International and national governmental regulations.if export shipment and l am the Primary a <br /> Exporter,I certify that the contents of this consignment conform to the tents of the attached EPAAcknowledgment of Consent <br /> I ceNy that the waste miniatzz9on statement identified in 40 CFR 262.27(x)(d I am a large quantity generator)or(b)INI am a smag quantity generator)is true. <br /> Gene srOFemes d Ied"' ane 51 Month Day Yea( <br /> c'uS cr rC-1 �5 C o 1 S z/ : <br /> 16.International Shipments <br /> f.., <br /> 1:1 Import to U.S. ❑apart from U.S. Pod of enbyyexit <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TmnsponerAcknowledgmenl of Receipt of Materials <br /> Tm er Pnnted/Frpad me J Spa re . Month Day ,Year <br /> a 1 t U erg T— —C.r V'G• �J Z- '—i <br /> z Transponer2 PdnteMyped Name Sig a Month Day Year <br /> B.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quanti <br /> ry Type Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V � <br /> a Facilitys Phone: <br /> w 18c.'�Walure of Alternate Facility(or Generator) Month Day Year <br /> 2 <br /> S2 . <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for h=rdous waste treatment,disposal,and recycling systems) <br /> 'aa I. 2. 3. 4. <br /> Nil fli��� y HP <br /> 20.Designated Facility Omer or Operator.Certification of receipt of harandom materials covered by the manifest except as noted in Item His <br /> Printed/Typed Name �— / Signaturj�eJ Month Day/ Year <br /> fz <br /> EPA Form 8700-22(Rev. -17) Previous editions are obsolete. DESIGNATED FACILITY COPY <br /> IF YOU RECEIVED THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST ACT.SEE INSTRUCTIONS ON REVERSE SIDE. <br />