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06/@1/2011 22: 52 2094655220 ABC FOOD MART PAGE 05/06 <br /> Please print or type. Form designed for use on elite 12 itch)WewftjForm Approved,OMB No.2050-0039 <br /> 1.Generator Q Nu 2.Page fcf 3.Emerge"R �ww Phone Z—ManRk Treating Number <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST 002844244 SKS <br /> S.Generators Nam and Mailing AddrM Generators Site Address(if different than mailing address) <br /> Generator's Phone' U.S.EPA 10 Number <br /> 6,TWpotter <br /> ­I.CompdriyNaMe.., <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ' <br /> s.Designated FaclW Name and Site Address l2 FC'ni-011- <br /> y ID Number <br /> I I V,�JL.F'54 I$ OF BF14TTY '-41Y T-5 <br /> K Et, <br /> Facilit Is Phone: <br /> 9,.7 9b.U.S.DOT oescripilon(including Proper StIAping Nam,Hazard r-tB-,ID Number, 10.Containers 11.Total 12.Urit 13,Waste Codes <br /> HIVI and Packing Group(I my)) No. Toe Quantity WtNDI. - <br /> A <br /> 0 <br /> S <br /> 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Fmtru�*m�and AddiiiInfo <br /> e proper shipping name.and are classified,packaged, <br /> 15. GENERATOR'SIOFFFROIrSCERnFICATION I hereby declare that the contents of this oons�nment are fully and amumtely described above by th <br /> marked and labeled1placarded,and are In all res)eats in proper condition for transport accordng to applicable international and national govemmental regular ons,If export shipment and I am the PrimaryExporter,I cerfiN that the contents of this Consig meat conform to the terms of the attached EPAAcknoWedgment Of Consent <br /> I certify that the waste minimization statement id infified in 40 CFR 262.27(a)(a I am a large quantity generator)of(b)Of I am a small quanffy generator)is true. <br /> Generatoes/offarDes Printacirrype<1 Name Signature Month Day Year <br /> J 16.Intemai"I Shipments El Import to U.S. El Fp,n from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S <br /> 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printedrtyped Name - Month Day Year <br /> I <br /> 4- 1-6. <br /> TianspoRer2 PrIntedfTyped Name Month Day year <br /> tY <br /> I B.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quanwy ❑Type ❑R.1011 El Partial Reject- ❑Full Rejection <br /> 18b.ARemate FacilityFacility(or Generator) U.S.EPA ID Number <br /> LL. Facilitys Phone: or 1enerator) Day Year <br /> LLJ M.Signa ty( Q <br /> Signature of Alternate FaCili <br /> 19.Hazardous Waste Report Management Method Codes codes for hazardous waste treatment disposal,and recycling systems) <br /> U1 3. 4. <br /> 20.Designated Faddy Owner or Operator.Certfttion of receipt of hazardous materials covered by Me manIfest except as noted in Item 18a <br /> Printed Name Signature Month Day Year <br /> EPA Fon 8700-22(Rev.3-0) Previous editions ai iq obsolete, GENERATOR'S INITIAL COPY <br />