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12171511 <br />Published by J. J. Keller & Associates, I.. • Neenah, WI • JJKeller.com • (800) 327-6868 • Printed in the USA <br />177-BLS-C 5 55359 <br />Please print or type. GENERATOR _.„ UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />QC 60--3 i 412-3 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />9[6- 543- 71/0 <br />vivici O. zUDU-UUJb <br />4. Manifest Tracking Number <br />['I 1 9 3 2.) 8 8 3 2 JJK Generator's Name and Mailing Address 0 bc4.62... /41411 6.41. <br />1651 cowl, l et 'vee <br />Generators Pho0ela-252- 454 -d‘e1RC jartrqi0L. ii • <br />ma{ Generator's Site Address (if different.thanirigling addressi)4/. <br />38, 15g4 b 121. 7--b172 ° , ig <br />A cello, 6 '7- <br /> <br />,4 520 <br />5-cu'l 1 I Transporty <br />ti <br />Company Name U.S. EPA I <br />EilOranknehlid 1 ) Ac , 1 CA- <br />I Number <br />000(73 &if I Transporter 2 Company Name U.S. EPA ID Number r v <br />1/112:65-9T7Y? 628 <br />=dress /1? <br />C6 <br />8 Designated Facility Name Oeri 1\14-Vaht, 1 PvC le US. EPA ID Number <br />117y <br />' VA/ K It I 1+Plf.S 50A 4.BeAtif <br />4-Vg1tot03 ,. ., <br />Facility's Phona- 2.3?- 3c43 N I Vi75301116006.. <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers - 11. Total 12. Unit <br />HM . and Packing Group (rf any)) No. Type Odarrfity Wt.Nol. - 13. Waste Codes <br />/161- Ket.A 4ç.45 Wo1/4* solick <br />(t.,6,,,Itid, 4- OGQ CF. 00g y 4 i1 -diesel, oido oil, 44 4 inipekerd soil. <br />2. <br />3. <br />._ <br />14 Special Handling Instructions and Additional Information(1& , t -Tirr.S Fccilcl if Ws 4 o 70 I PE. 306- I 775-7 . . . . <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard are classified, packaged, <br />marked and labeled/placarded. and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary . <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acialowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I urn a large quantity generator) or (b) (if lam a small quantity generator) is true. <br />Generators/Offerors Printed/Typed Name. - Signature • Month Day Year <br />A ulhori red 44-1- ro r 01.11Aele7 4.141 /I' knrar Arif P 3 _I°8P lao <br />f-- <br />16. International Shipments <br />Import to U.S. Export from U.S. Port of entry/exit . <br />Transporter signature (tor exports only): Date leaving U.S.: . TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />M AS 114,11 nfi77grw5 I 77/cat.dZeilta t_LtvAz_ 103 10 612,- <br />Transporter 2 Printed/Typed Name Signature Month Dui_ Year <br />--r.hiAveZ- Zate.4471ed 1-4.--/--. Z-4 ,./ 1 7 1/5 1 DESIGNATED FACILITY I 18. Discrepancy <br />Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone' I <br />Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1 2. 3. 4. <br />20. Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />I I I I <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM