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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generalor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> ' UNIFORM HAZARDOUS i0 12 ^ 760 JJ K <br /> WASTE MANIFEST I 1�',ip <br /> 5.Generators Name and MailingAddress Generators Site Address(if different than mailing address) <br /> ft'r-'S:4 S.JNf�''t_W4 V�'JA r <br /> "(Y'li-+VT!'){'} '`A 0541.i� <br /> Genera <br /> Phone: 1,1 '3 'r '� . ? <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ' 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desornted Facillty,*Ine and Site Address U.S.EPA ID Number <br /> ft% 4ti <br /> E91i 11 f1'r ►3syrp'1: <br /> Facilitys Phone: <br /> ' ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit 13 Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity Wtivol. <br /> tY J, <br /> O <br /> — 2.• r.i., 'Azi11'crO+.lii..'i.i a;p ,rr,x 3 Ii.,- 4lil •'''ep$Y�I.Crr•,h.rjrdo` i11i1'i r"1r L�flt�(; <br /> LU -x ,Aft+ <br /> ' 3.'Ir'.{; !{� a.'1, ct„',7x'f NIrt <br /> ' 4.:irJ{'rI*r:.!<'i:l i.l.dr1 .m6 t+rrOlS{M ;'�C M (+,.. ;A.t,i�:,(beiritl`_•+KllII r <br /> 1 . ped Handling Instructions and Addlional Informetiorl t t : V'.,, It _ 4 1 11} <br /> t.�(.�.,!•�f`}rE►�'1!141t'+iiul I i iatyll ':t ttll,f..;;{1f;�,R..jlw�Al i1P'1•tlftfli!It;r'I S?#y tijfl�•IJ'1 it, <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 international and national governmental regulatons.If export shipment and I am the Primary <br /> Exporter,I certify thal 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 21(if I am a large quantity generator)or(b) am a small quantity generator)is true. <br /> Generatoes/Offerors PrintedrTyped Name Signature Month Day Year <br /> J 16.International Shipments Port ofent /exit <br /> - Import to U.S. ❑Export ry <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> ' W 17.Transporter Acknowledgment of Receipt of Materials MonthDaj Year <br /> Transporter 1 Proted/Typed NameCL <br /> J <br /> Month Day Year <br /> Q Transporter 2 Printed/Typed Name Signature <br /> F-- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ElQuantity ❑Type ❑Residue Partial Rejection ElFullRejection <br /> ' Manifest Reference Number: <br /> i8b.Alternate Facility for Generator) U.S.EPA ID Number <br /> J <br /> ' U <br /> rai Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> ZZ <br /> ' 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ1. 2 3. 4. <br /> 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> ' Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />