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3oa.55� r' <br /> Please print or,type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking umber <br /> WASTE MANIFEST �[- 3S�Q3 g66-�?33-g uZ 0 02709681 FLE <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> POLE PAe-W 44Ca r-ooOS LLG - SroG6tTG,.J <br /> 79 1& igEtl.evo � 2e Jla6g FL i01AJIgL Q� <br /> A-Tc✓s1-Tee, d4 IS3ol ��-pGlcro.�J, G'A 9SZo�� <br /> Generators Phone: 20 9- - <br /> 6.Transporter 1 Company Name U.S.EPA ID Number �0�0 0 70.SzI0 <br /> A0VANG�O eNc..t,c.at- -re 4 V:/ #doe T CA <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> /j, 6 D y- <br /> v <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> G'L A��U 14AOZ03o¢S OF Sq,J SDs E r L t-G <br /> (OZ_ 1 X S je 12 / `!g.% 20 4 0 <br /> Sa.�l aosE ea 4x133 <br /> Facility's Phone: t40 16 - q y J _b 7&2CA 13.0'5-9 fif <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt./Vol. <br /> X 1 (fAJ321W"YL e Gt9LeoSiJ� Lc�.2✓1�, AGrOzG <br /> lb o2 931 <br /> �( EE74tGan/�G �-o.S., �Ls►v�r�c /4G�O)r 8, plr.� � i�� .SS !� <br /> UJ 2. <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> 14.S al Handling Instructio s a d Additional Informatio <br /> I) i�rs '�T��adc-oo �) LHyso9�2 <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.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that 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 /> Generators/Offeroes Pnnted/Typed Name igna re Month Day Year <br /> 107 12ql 10 <br /> J 16.Inte do al Shipments <br /> z ❑Import to U.S. ❑Export from Port ot lexd: <br /> Transporter si nature for exports only): Date leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> cc <br /> Transporter 1 Pnnted[Typed Name Month Day Year <br /> O <br /> CL 7lzg , <br /> UO) <br /> Q Transporter 2 Printed/Typed Name ure on h Day ear <br /> 7� t� /9 / <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> Facilitys Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> r, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) <br /> p 1. ��) 2. 77- <br /> . 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except a oted in Item 18a <br /> PrintedRyp me� � Ath,4� <br /> Signature � Month DYear <br /> ` f�/ 6 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY T INATION STATE(IF REQUIRED) <br /> 10768.1551 <br />