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-Pleasd'print or type. (Form designed for use on elite <br />1 UNIFORM HAZARDOUS 1 Generator ID Numt <br />WASTE MANIFEST (` AJ rvra ►nom-: <br />. s W C BA Attry M cgs i �..�: <br />reW <br />14tv-4rIld-m 8*'A aR:lka <br />s <br />Form Approved. OMB No. 2050-0039 <br />2. Page 1 of 3. Emergency Response Phone 4.Manifest Tracking Number <br />i .F. fi 08025/00 FLE <br />'kAM AD d Cit-df"C86 .eta U: <br />ol►a iabC. �+�vi r <br />€>d; Ea�y mow. <br />e i F ! 1 P"emi o <br />Facility's Phone: "175-2A- 0 <br />ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />W ?Ncm-RC:RA Ha tzo(kms it awc- Laitdar 31$g't3 <br />0 f <br />LU <br />Z 2LI1 I 7+'alll't)h �8 b0lli K0.5. NX41lei7 14CdYl <br />0_ N <br />Iain <br />ID <br />N#U"i; iomm) <br />10. Containers 11. Total 12. Unit <br />No Type Quantity Wtivol. 13. Waste Codes <br />��w 1 1,� <br />l� tYT9)��r�f1i-xii�?.1 �_s' A., �.� `_ �`"'*� .;�x�1�4, t➢t'(.193�Ytit-3��9 3Fkd.1^+ �.e.",...`"�.,..t... I X <br />hat the contents of this co ignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />16. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby dedaie t <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 />nerators/ erors Printed yped Name ignature <br />` ort ay <br />J 16. Intemanonal shipments •' - b-�,r <br />F-- ❑ Import to U.S. Export from U.S. Pod of entry/exit: <br />Z Transporter signature (for exports only):— - <br />Date Ieavin U.S.: <br />w 17. Transporter Acknowledgment of Receipt of Materials <br />I. - <br />ex Transporter 1 Printed/Typed Name <br />O <br />Signature Mont ay <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑ Type <br />F} 18b. Allemate Facility (or Generator) <br />J <br />U <br />Q <br />�- <br />Facility's Phone. <br />W 18c. Signature of Alternate Facility (or Generator) <br />Z <br />❑ Residue ❑ Partial Rejection , — Full P,eje 4uon <br />_ <br />as a p1 <br />Manifest Reference Number. <br />U.S. EPA ID Number <br />SEP 0 8 2015 <br />Month _Day Ye( <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />20. De 'gnated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest exce t as noted in Item 18a <br />PrintedlTyped Name Signature <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete <br />TRANSPORTER'S COPY <br />