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r <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1tGeneW6rID;Ad6iber u 11 � 2.Page 1 of 3.tEmergency$2espbnse Phone 4.(MaaniifestTracking <br /> 'Number <br /> WASTE MANIFEST V 0 8 3 U 1.1'2 F L E <br /> 5.Generator's Narne andrMailingAddressW o Nt3 f?et i Generator's Site Address(if different than mailing address) <br /> z 4i'is•'s. A)wc4l wav y!!tid31[ <br /> r"�r+,ctt�►�_�eta=* <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> r:'ie�tr tt >f�tzr i.fr rs��et r ►t *s'taria 4rtu M to 110 ;a 9 3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 2-X00 Nat-MAaws Road U t x,:x sa L L$4 4-L s r <br /> Ir iA-toa <br /> Facility's Phone: "351 SIX 1N) <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(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> Q' 1.FIA309-4 RAZARMUS WASTE.LIQUID,IINA&,WiNIZEIRE, 0018 <br /> t1`�.x~:��ANE1.9.Ki lit Fl M <br /> W <br /> LU <br /> 352 <br /> 3. <br /> 4. <br /> U <br /> 14.Special Handling Instructions and Additional Information <br /> 3.011991942-r <br /> 2 clfr€f lgrtf^_; <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 regulations:If export <br /> }�ipment 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 quanfify generator)is true.' <br /> Generator'sl0fferor's� ed/Typed Name ., igna re;- _ - 7-7a ear <br /> J 16.International Shipments �r <br /> - ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature for exports only): Date leaving U.S.: <br /> ar 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJTransporterwi-Printedffyped Np ^� Signature , n a . ear_ _ <br /> IL <br /> QTransporter 2 Pdntedlryped Name Signature Month Day year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type <br /> ❑Residue El Partial Rejection ❑Full Refection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> CD <br /> LL <br /> Facility's Phone: <br /> U 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 /> LLJ C 1' X1040 2' 14040 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 /> fvost f•1v+orA hgn 1,110Appirov,*00 pelmits(Or fazid ill Atr€91 Rw wavxe(ke fecs€"ae41t is <br />