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Please print or type. (Form designed for use on elite (12 -pitch) typewrite <br />—r <br />I UNIFORM HAZARDOUS 1. Generator ID Number <br />WASTE MANIFEST <br />5. Generator's Name and Mailing Address <br />s1D{'a4st3�}��i�i A Sli'miktio li Uo",tt6mi U'r, <br />,:� 1 �: ? :Tai: 11i➢74 '�f !..M. <br />05,z* <br />Generator's Phone '#` -4 , . `% <br />6. 1 ransporter 1 ompany Name1-h1w, -10Tfampw 4x- (8,V111 <br />riEwrl S�r INV - <br />Facility's Phone: <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />O <br />2. Page 1 of 3. Emergency Response Phone <br />U.S. <br />ID Number <br />Form Approved. OMB No. 2050-0039 <br />ng Number <br />� 0649 FLE <br />a d1Pt0%#07V-�.� <br />10. Containers 11. Total 12. Unit <br />No. Type Quantity Wtivol. 13. Waste Codes <br />L <br />1r F: 4.tr i:3i 1Ea i+Ff d Tw <br />15. GENERATOR'S/OFFEROR'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 intemational and national governmental regulations. If ekport 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) (if I am a large quantity, generator) or (b) (if I am a small quantity generator) is true. <br />Generator's) eros Printed/Typed Name igna ure Month Day <br />J 16. Intemational Shipments <br />Z 1:1 Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature for exports only): Date leaving U.S.: <br />L 17. Transporter Acknowledgment of Receipt of Materials <br />Signature Month a Year <br />Z ITrancnnrtar 9 P loriri d nr <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑ Type ❑ Residue ❑ — <br />Par('iali2ejec�t4ft ,, -, � �rFattitejection <br />18b. Alternate Facility (or Generator) Maniest'Reference Number. <br />J <br />U.S. EPA ID Number <br />a - <br />� <br />Facilitys Phone: SEP 08 2f11� <br />W 18c. Signature ofAttemate Facility (or Generator) <br />Z <br />EN N 'N' Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />rW, 1. 2 3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedfTyped Name Signature r Month Day r�.r Year <br />I <br />:PA Form 8700-22 (Rev. 3=05) Previous editions are obsolete. TRANSPORTER'S COPY <br />