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Please print g ( P )�,pe ) .(A�... <br /> p type.(Form designed for use on elite(12-pitch) writer. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 13.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ; 00 h �6 3 M W I <br /> 5.Generator's Na� n�a,aand.Mallingq��res� Generator's Site Address(if different than mailing address) <br /> 1�0t1u'�is#0 WP-4•lifE#>.,Xv tv4Rfi+s+titl t,:yt4# 3any <br /> me rc►t#,�.A 1074',FUS; <br /> Generator's Phone: <br /> rtrtl�ppaa Y d:•_ <br /> 6.Tra <br /> n�ortie4Cit'Sita ! $�idid#3tA(Yi+?#kri� i&'tix; 3 #tL _ U.S.EPA ID Number , <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> JUIv � 1 2011 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> f::£taaatt��I�r3�#c�sl~+4ttio#►t6atrE3��: �,id,}�1:� .:'.'CQISNi`� <br /> 2W [d'St I<.42t!l4iwE2 Rawl t•.,,.,,...,ENTAL , <br /> Facility's Phone: its+ <br /> ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol.¢` ;0Z,jf) ' 0`"a..jI.. <br /> (Y f" <br /> 0 'Y. <br /> w <br /> 1aA I fA7A.caffti <br /> 1 JAI <br /> 11) <br /> 3. r � 0 <br /> 4. <br /> 14.Speclal f!�Handling Instructions,�nd1ibop5J1 Information <br /> T i-} �++ aa��PR <br /> 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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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 Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoeslOfferoes Printed/Typed Name Signature Month Day Year <br /> -1 16.International Shipments <br /> Z ❑Import to U.S. El Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LOC 17.Transporter Acknowledgment of Receipt of Materials <br /> Tran§rder 1 Printed/Typed Namp N Signature !� Month Day Year <br /> M Transporter 2 Printed(ryped Name Signature Month Day Year <br /> Q <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue ❑Partial Rejection El Full Rejection <br /> } Manifest Reference Number. <br /> ~ 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1• diB.,-,; 2. 111.:.fa 3. 4. <br /> i <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedfryped Name Signature Month Day I Year <br /> I <br /> EPA Form 8700-22 Rev.3-051 Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 4-Ew Att A' lLi b''.Vt ao.xr.d't+:. x.3a»hs.,c:r0,v c�ury+a,rf.,#nx -A-ilk , ,...,.. ai,n.,., ct.� d,...,....:..-:. ..e...._.._.. <br />