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Please print or type. (Form designed for use on elite (12 -pitch) typewrit, <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />WASTE MANIFESTrti, <br />5. Geenerator's Name and Mapilliing( Address ) / j q { <br />f i ae; r i C7 Jifit>iwa,s L*A :",:t>tf r t t,ri<! f. , s jjt.;eu Owl 6t <br />A1Y71 q:t� Ncdll. i 4 <br />2. Page 1 of 3. Approved. OMB No. 2050-0039 <br />Emergency Response Phone 4. Manifest Tracking Number <br />1 <br />7 T <br />U.S. EPA ID Number <br />U.S. EPA ID Number <br />I <br />u J' U.S. EPA ID Number <br />BOX L <br />:: vw !ir <br />Facility's Phone: <br />ga, 91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers <br />HM and Packing Group (if any)) 11. Total 12. Unit 13 Waste Codes <br />� ,� �! "�'?'"�;�`I';"`d.'`�;'F?ft'"'?,li,.^'�,;i"�:Tifi�TM-wi4t�4ff��.r-�-r��-^.....--•......� No. Type Quanfity WtNol. <br />'1 <br />AN'n <br />j Fh*vtt l4tf ibm. 6,jM 1WV rfn t. F7TJ&6 <br />15. GENERATOR'S10FFEROR'SCERTIFICATION: <br />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 'If <br />and national governmental regulations. export shipment <br />Exporter, I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br />and I am the Primary <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator orb if I am a small uanti <br />enerator' ero s Printed/Typed yped Name ) () ( q ty generator) Is true. <br />Signs re <br />n ay ear <br />F16. International Shipments <br />z ❑ Import to U.S. ❑ Export from <br />U.S. Port of entry/exit: <br />Trans orter si nature for ex arts onl <br />U 17. Transporter Acknowledgment of Receipt of Materials Date leavin U.S.: <br />Transporter 1 P I! ed/Typed Name <br />C) rgnature <br />n ! <br />ont ay ear <br />Transporter2PrihtedJTypedName} _t t •'�+t"` <br />t,;`a, 7 a. <br />r Signa re <br />Month Day Tear <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑ Type ❑ <br />Residue ❑ Partial Rejection <br />1 <br />❑Full Rejection <br />= 18b. Alternate Facility (or Generator) Manifest Reference Number. <br />3 U.S. EPA ID Nur$?er <br />C <br />- Facility's Phone: r <br />mtxiin- Uay <br />Z <br />u119 Hazardous Waste Report Management Method Codes (r a codes for hazardous waste treatment disposal and recycling systems) <br />-0. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Prmted/Typed Name <br />yl. Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions arerobsolete <br />TRANSPORTER'S COPY <br />