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Please print or type.(Fol designed for use on elite(I 2-pidl 1:ypevirviler.) Form Approved.OMB No.2050-0039 <br /> IUNIFORM HAZARDOUS I I Gerieralor 10 Number 2.Page 7177F3.-Emergency Response Phone 4.Ibibit T AnOumber <br /> WASTE MANIFEST "� P14: $ i 11-1 lf.'JiW C I T- . 4341JJ K <br /> I-n Generators Name and Mailing Address Gererall Site Address(if different than mading addivilw <br /> It <br /> Generator's Phone: <br /> 5.Transporter 1 Company Name U.S,EPA ID Number <br /> it".14 5:.. t <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> A, fJANAl i,'' l Vx is :C <br /> 8 Des4grialed Facility Name and Site Address. U.S EPA ID Number <br /> P <br /> ONI A W-4015 <br /> Faall Phone; <br /> 9a 9b U.S.DOT Desciription(including Proper Shipping Name,Hazard Class,ID Number, Ic Containers 11 -otal 12.Unit 13.Waste Codes <br /> HM and Padang Group(if any)) No Type Quantity WILMI <br /> 7. -77 <br /> 0 <br /> Z 2 <br /> LU <br /> -7 --- <br /> I <br /> 3. <br /> 4 <br /> 4.Special Handling Instructions and Additional Informaltion. <br /> 4 t- <br /> .00% '' '1 1-'�it <br /> .00% <br /> 15. GENERATOR'SIOFFEROR'SCFRTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the;)toper shipping name,and are cassified.packaged <br /> marked and labeledipLacarded,and are in all respects in proper condition for transport according to appiltern <br /> international and national governmental regul 11 export shipment and I am the Primary <br /> Exporter,I cel that the contents of this consignment conform to the terms of the attached EPAAckricwledgment of Consent, <br /> IF I certify that the waste minimization statement identified in 40 CFR 262 27(a)(If i am a large quantity generator)or(b)tit am a small quantity generator)is true, <br /> eratoes101feri Pnntecl Typed Kamp Signature r Year <br /> [16.Interviatol Shipments <br /> F- El import to U.S. L]Export from US Pori of entrylexilL <br /> Transposer signature(for exports only). Date leaving U <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> ��er,l Printed(Typed Name --I Mon Ua� !,N <br /> t+ <br /> C Transporter 2 Printed/Typed Name Signature l Day Year <br /> ix <br /> 18.Discrepancy <br /> 18a Discrepancy indication Space Qual I J Type ❑Residue ❑Partial Rejector ❑FLX Rejection <br /> Manifest Reference Number <br /> '8b,Alternate F,)cjlity(or Generator) US EPA ID Number <br /> Ln Facility's Phone: <br /> LQ 18c Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal•and recycling syslerl <br /> 4 <br /> 20 Designated Facility Owner or Operaton Cenftabon of receipt of hazardous materials covered by the mol except as noted in Item 18a <br /> Printecl Name Signature klcn!� Dav Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />