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Please pant or type {Form designed for use on elite(12-pitch)typewriter.) Form Approved.GY B No.2050.0039 <br /> UNIFORM HAZARDOUS_I I Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 000 %300814 GBF <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generab's Phone: <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> �­-t.tnqa enqkcjnitk-jq.ij ii:, I ,,q*"�g wt I-I,!I! <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.De ted Facility Name and Site Address U.S.EPA[1)Number <br /> G)"Z'Z', '1.1 C. i �i7n' Afl 40�1 1A <br /> 'Aellwe Pips)!' P03 4 <br /> �4hrw�t!"Gcirlowv. <br /> Facility's Phone: Jii, "..'to.k,;' <br /> 9a. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard CPass,ID Number, 10.Containers I!.Total 12.Unit 13.Waste Codes <br /> HM and Packing Grew(if any)) No. Type ovantty wtivol. <br /> Iz 2. <br /> uj <br /> 4 <br /> '4 Special Handfing Instructions and Additional Information <br /> I-NU&L�6 1C, LIE 4u 1 f�qM, 0 Atli} Off: <br /> P ERG.on.,i <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATION: I herelyy declare that the contents of[his consignment are laity and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplararded,and are in all respects in proper oorifton for transport according to applicable intemal and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify th,,V the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Con". <br /> 11" )certly that the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(IfI am a small quantity generator)is Tue. <br /> Worm(sl0fibrors PtinteVyped Name Signature Month Day —Yeairr . , <br /> k'N, <br /> 1-4 16.International shipments <br /> I'_ M import to U.S. ❑Export from U.S Port of eril <br /> K Transporter signature(far exports only): Date leaving U.S.: <br /> 2� 17.Transporter Ackmw1edg!t of Receipt of Materials <br /> U nl11 17 r, yew <br /> Transpoiller 1 PTintedl 1111100111`�. oNArre <br /> C) <br /> CL <br /> Tr—ansporier 2 Arinleciffyped Name Signature Month Day Year <br /> cc <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type [I Residue L1 Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> ::3 <br /> LIC Fadlitys Phone <br /> 0 <br /> u1j Ilic.gignalure olem-ate Facility or Generator) Month Day Year <br /> R.Hazardous Waste Report Management Method Codes(i e.codes for hazardous waste treatment,disposal and recycling systems) <br /> 2 3. 4. <br /> 20.Designated Facility Owner or Operator Certification of receipt oilhazardous materials covered by the manifest except as noted in Item 18a <br /> Printed,rryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />