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Please print or type.(Form designed for use on elite(12-pitch) ler.p', Form Approved.ON18 No.2050 0039 <br /> T UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> wuvvv �.� � //- iib )1 00U!'+ U .j892 JJK <br /> r + � u <br /> ,,,alols Name and MaOing Address Generators She Address(f different than mailing address) <br /> C3P (,urs-f- ��n4s� p/9d�Ju s <br /> �7Uo W-es->t cu►aS4 r n.9 �, f <br /> Generator's Phone: GCAkj, rf} '2 p <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 71GA <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address r r . y L C U.S.EPA ID Number <br /> da R,S �r'1 �U J <br /> Facility's Phone: 64 <br /> ga 9b.U.S.DOT Description(including ProperSHlpp6tg Name,Hazard Class,ID Number, �0.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt Not, <br /> ,. Non ---1?(' 9A NAZ ApJa6 <br /> 9/un <br /> Z 2. <br /> w <br /> C7 <br /> 3. <br /> 4. <br /> Special Handling Instructions and Additional Information <br /> 1(� ( I Ify, <br /> t4AI c f'►,1rrc/l.��l ; � ; „; <br /> 15. GENERATOR'SlOFFEROR'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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to appf cab!e 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 EPAAcknonledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262 27(s)(if I am a large quantity generator)or(b)(f I am a small quantity generator)is true. <br /> Month Day Year <br /> GeneralorslOfferors Printed/Typed Name Si 9 <br /> .J <br /> 16.International Shipments ❑ P <br /> Im ort to U.S. ElExport from U.S. Port of entryfexlt: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.Transporter AcknaafedgmentofReceipt ofMateria's <br /> � Transporter 1 PrinleCyped Name Signature Month Day Year <br /> O ' ) j I I I I C)*6 <br /> . Month Day Year <br /> ZTransporter 2 PrintedRyped Name Signature <br /> Q <br /> 18.Dscrepancy <br /> 18a.Discrepancy Indication Space L1 Quantity LJ Type ❑Resiclue L]PartialRe)echon ❑Fo'I Resection <br /> INI 1 <br /> `c�5 5htlulb f�cc:r/X , NA3b$2 OAZArrW'•"S <br /> "O <) )_0 (1AQB oh Manifest Reference Number. <br /> 18b.Alternate Facility(or Generates) Fl U.S.EPA ID Number <br /> Zi <br /> U <br /> I Facolity's Phone: <br /> W 18c.Sgnature of Alternate Fac-14y(or Generator) Month Day Year <br /> ZZ - <br /> Hazardous Waste Report f,lanagement Method Codes(i.e.,codes for hazardous waste ueahnenl d sposal,and recycling systems) <br /> f 2 3. 4. <br /> 20,Designated Facility0sner or Operator:Certification of receipt of hazardous materials covered by the manlesl except as noted in Item 18a <br /> Prinled/TypedNam S!gnaturei Month Day Year <br /> 41 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESI ATED FACILITY TO GENERATOR <br />