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Please Ddrt or tvoe_ !Form dasinnad fnr i ma n„ or+o hm,...._. % <br />GENERATOR'S INITIAL COPY <br />Form A roved. OMB No. 2050-0039 <br />FORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />FIF5GeneratoesrName <br />ASTE NIFEST " O U ( �+ �� <br />and Mailing A�dclress., Generator's Site Address (it different than mailing address) V' <br />d:. <br />Generator's Phone: <br />B. Transporter 1 Company Name <br />yV); j. .r: ..IV a '? I" °I. U.S. EPA ID Number <br />_. <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />;r U.S. EPA ID Number <br />Facili 's Phone: ct <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />HM <br />and Packing Group (if any)) <br />11. Total <br />12. Unit <br />13. Waste Codes <br />1;4, i <br />No. <br />Type <br />Quantity <br />Wt.Nol. <br />h'A i�fh)'v'. i,,: ��FUit `iUIILlr lli1.T �Ui_IU PAJFLR FI1.ki:fi.1 <br />O <br />H <br />w <br />z <br />2. <br />w <br />t7 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />. r4 r.!fr r " 1 $til►-4�,1+9j0.r rat,!_.:, !t F;n:u,•,, rlit. t'kl4'1.1. • ALI i6: hloNhwlihY,.ih <br />!IIY1.4►1)IJ PAPFV91ff`P- APPILN)Pf7t11Ii P'FFt''.,WiiAt,V',(!It!:f <br />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 labeledlplacarded, 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, <br />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 />Generalors/Ofierors PrintedlTyped Name Signature Month Day Year <br />16. International Shipments ❑ <br />Import to U.S. ❑ Export from U.S. Port <br />— <br />of entrylexit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />UA <br />17. TransporterAcknowledgment of Receipt of Materials <br />Transporter 1 Printed(Iypad Name. Signature <br />O <br />Month Day Year <br />22 <br />Transporter 2 Prfnted/Typed Name j Signature <br />Month Day Year <br />F <br />18. Discrepancy <br />1Be. Discrepancy Indication Space ❑ Quantity ❑ Type ❑Residue ❑ Partial Rejection ❑Full <br />Rejection <br />Manifest <br />Number. (or Generator) <br />18b, Alternate Facility, (or <br />J <br />U.S. EPA ID Number <br />V <br />I <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />a <br />Month Day Year <br />z <br />O,—n <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. <br />3. <br />4. <br />20. <br />Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br />Printed/Typed <br />Name Signature Month Day Year <br />:PA Form <br />87DO-22 fRav 3 D51 pmvinnc a,ttl;,,. <br />GENERATOR'S INITIAL COPY <br />