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Please print or type, Q079543933K3Form Approved.01MB No-205N039 <br /> UNIFORM HAZARDOUS 1 Generator Ill Number 2-Page 1 of 1 3-EmFe eney Res-P"Phone 7007984393 <br /> nifest Tracking Number <br /> WASTE MANIFEST }: 7, i:.'•;? .;.;',�;; �'-r 5 K5 <br /> 5.Generator's Name and Mailing Address Generator's Site Address('d different than mailing address) <br /> � ;r E'T i'- <br /> Is BOY, 5f,5 <br /> Generaloes Phone: <br /> 6,T n T CampprIIyyame U.S.EPA ID Number <br /> 7,Transporter 2 Company Name U.S.EPA fl)Number <br /> 8-Designated Facility Name and Site Address (r:i ;�•,� riF r,j1 T r 0 QN J P1 U.S.EPA ID Number <br /> ] <br /> r1=t ear,;;TH AVE <br /> s <br /> 510 95S----440.0, C~ ),:-18 t:,,S74 f <br /> Facili s Phone: - <br /> ga- gb-U-S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10-Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)} No. Type Quantity Wt ivol- 13.Waste Codes <br /> 1' NON--RCRA HAZARDOUS WASH=. LIQUID <br /> F (USED QIL) <br /> a4 ` IC) 11 <br /> x 2. <br /> W <br /> U' <br /> 3, <br /> 4, <br /> 14.Special Handling Instructions and Additional Information TSD:EVC S,AL CSS <br /> E:4H EMERGENCY#800--4'EL-f7iEO_C:ri.'fiF,/iFI--Contract retaineC- by genet,at,nr- con-fers a enc y ar.:.trl : ., . <br /> 15- GENERATOR'SIOFFEROWS CERTIFICATION: i hereby dedare that the contents of this consignment are fully and accxrnately described above by the proper shipping name,and are Classfed,packaged, <br /> marked and labeledlpiacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.ff export shipment and I am the Primary <br /> Exporter,I oar*that the contents of this consignment conform to the terms of the attached EPAAdvwwledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(ff i am a large quantity generator)or(b)(d I am a sm ua enerator)is true. <br /> GenerataYsJOlfe s Printed lTypad Name Signature Month Day Year <br /> r 1 L <br /> 16.IntamMal SlIlpments <br /> ❑Import to U.S. ❑Export from U.S. Part lexit: <br /> Transporter signature(for exports only): Da caving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> A If <br /> Transporter i P' edlTypad Name A Signature ! Month Day Year <br /> 0 <br /> Z Transporter 2 NntedlTyped Name <br /> CL <br /> Z] <br /> Signature Month Day Year <br /> f- <br /> 18-Discrepancy I�I f�1 <br /> 18a.Discrepancy Indication Space [IQ ua,tity ❑Type ❑Residue ❑partial Reject,, ❑Full Rejeodon <br /> Manifest Reference Number: <br /> 186.Alternate Facility(or Generator) U.S-EPA ID Number <br /> C.� <br /> Fac lW,Phone: <br /> aH 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> w19.Hazardous Waste Report Management Method Codes(Le.,codas for hazardous waste treatment,disposal,and recycling systems) <br /> A 1. }10.11 2 3, <br /> 4. <br /> 20,Designated Facility Owner or Dperator�Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed Name Signa Mond Day Year <br /> 1rea�. Dom./ � - Z <br /> EPA Form 8700-22[Rev.1717] Previous editions are obsolete. ESI ATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />