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DISC 888. 2358 <br /> Please print or type. Form designed for use on elite 12-pitch typavariter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID NumberQ 2.Page 1 of 3.Emergency Response Phone 4. an t racking Number <br /> WASTE MANIFEST C,4 -01914'S [ 9�I�J 1 1. is00.`(t.y• C, 16021081 JJK <br /> 5.Generators Name and Maung Address Generalors Site Address(d d'dferent than malting address) <br /> Stis11 i2AZGwA`J Go, <br /> 710 ah R-Aja Ui 6 D R So i DzA/4 0 P s <br /> $ 1f N aE(LA✓ktZ-DZn�o� C�} q�tic$ STo GK'orj , C-A el15Z06 <br /> Generators Phone: L <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> mentaI L-ftilift,Inc. C A R 0 0 0 2 1 7 5 1 3 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and She Address U.S.EPA ID Number <br /> FMW RecydMo SWVIM,IM <br /> 180 W.Motes vmetim <br /> Bbombiglon CAt1 CAD982444481 <br /> Facri' sPlwne: M 4j' 1-WI�$ <br /> ge 1 91).U.S.DOT Description(includ'amg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13,Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity WL/Vol. <br /> 1. 1 000 <br /> o N DJ j2-c.Rh NR'tPa R-vovs WA t tri f c z p p Z DM � 35 Z <br /> C F0GK DEaX%--r a-/w d=L, <br /> z 2. <br /> W <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information l) M 6867 <br /> 1.0) R-am 9 ocaRw ch-, dZL 2,--V55 N`V032152.1 <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.N export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(d 1 am a large quantity generator)or(b)(if 1 am a small quantity generator)is true. <br /> Generators/Ofierors Printaffyped Name Signature Month Day Year <br /> Q 1 /0 <br /> �r 16.Intematonai Sh"mprnants <br /> � ❑Import te U.S. Export from U.S. Port afentry/exit <br /> 2 Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAGmowtedgment of Receipt of Materials <br /> Transporter 1 Print yped Name Signature Month Day Year <br /> F zarE Sz4t6 <br /> UR) <br /> TranspoRer 2 Pdntedtfyped Name ' ature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facrlitlls Phone: <br /> W 18c.Signature of Allemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes p.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1. hq <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operatw.feertilication of receipt of hazardous materials covered by the mans t as Hoed in i 8a <br /> Printed/Typed Name Sig re i q Day ear <br /> A V -A- <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 12378.1643 <br />