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.Alease print or type.(Form designed for use on elite(12-pitc pewriter.) <br /> UNIFORM HAZARDOUS 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> 2.Page 7 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST r./'E1)11(1�1t3288 A 7 �' D <br /> i R' iP f D <br /> 5.Generetor's Name and Mailing Address Generators Site Address(if deferent than mailing address) <br /> INDEPEK)ENI TPW,i(:'VUPk3 <br /> 114a W oviv f6fi it <br /> ST ohITON,('.A 86'X <br /> Generelots Phonei,YY,ki dt3P.1�S11d'21tYs <br /> 6.Transporter i Company Name <br /> r;NCIF'h1AZ.yiIR(7F„btiH.UT'fr3f1+�,iPV;` us.EPAID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> • • (_((; U.S.EPA IDNumber <br /> � r <br /> I• <br /> I - <br /> I •• � ' f"i L •� C <br /> ]mber, 10.Containers 1 r V it.Total 12.Unit 13.Waste Codes(,�-f y� No. Type Quantity <br /> WlNol. <br /> C Postage /+� Caht 1� P J152 I <br /> Tl Cued Feer/ /y 7y - <br /> Here <br /> a <br /> Reform Receipt Fee <br /> C3 (Entl"duumRequlretl) <br /> C3 %Jgdcted D11"rY Fee -- <br /> C3 (EMrxeard Required) <br /> C3 Total peg <br /> i, <br /> OC3 <br /> r <br /> or pO faox S f.:.--.--- <br /> r <br /> ATE F'SiCiTU IVE t' -01"W"[W;#171 <br /> S'MF Pk. jh r C.CrN I'U I I)At t.Ale(vr}:IiAEi. <br /> Vmarked <br /> TOR'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 /> and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> ,I cedify that the contents of Nis consignment conform to the terms of the attached EPAAcknoWedgment of Consent. <br /> hal 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 /> ferors Print typed Name Signature Month Day Year <br /> al Shipments ❑Import to U.S. ❑Export born u s Pod of entry/exit: <br /> Transporter signature(for exports only): -.--- -_. <br /> Dale leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 P' tedrryped Name Signature <br /> a Month Day Year <br /> 4 Transporter 2 Prinlecirtypeo Name <br /> Signaru Mon h ay Year <br /> 1-- <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type El Residue ❑Pallial Rejection 1 ❑Full Rejection <br /> 100.Alternate Faciley(or Generator) Manifest Reference Number <br /> ..a U.S.EPA ID Number <br /> V <br /> ra+. Facilitys Phone: <br /> W 18c.SignaNre of Altemate Fadlity(or Generator) <br /> C Month Day Year <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1. 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 /> Prinled/Typed Name Signatureit Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />