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Please print or type.(Form designed for use on elHe(1&pitch)ty r.) <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency R Form Approved.OMB No.2050-0039 <br /> WASTE MANIFEST espouse Phone 4.Manifest Track! Number <br /> k <br /> Name and Mailing Address Generators Site Address(if than manhnn z� 713353 FLE <br /> 5 Generators <br /> . ( dress) <br /> Generators Phone: <br /> 6. r'ansporter 1 mpany am <br /> — - U.S.EPA ID Number <br /> 7.Tmnsporter2.,..ry Name <br /> U.S.EPA ID Number <br /> S.Designated Facility Name and SHB Address <br /> U.S.EPA ID Number <br /> Facil"Phone: <br /> F3. <br /> oncluding Proper Shlpping Nemo,Hazard(Mess,ID Nurtder, MM <br /> ; U {3 r �t t•. <br /> )) 12.Urdt <br /> kAbl. 13.Weate Codes <br /> 0 <br /> tl 6. <br /> 274Af It <br /> 14.SpecialHandlinglnstructionsandAdditional Information - <br /> 15. GENERATOR S/OFFEROR'S CERTIFICATION: I Hereby dedare 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/placarled,and are in all respects in proper condition for transport according to applicable intema dal and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cer*that the contents of this consignment conform to the tamw of the attached EPAAdmo vedgment of Consent., <br /> I rer5fy that the waste minimization statement identified in 40..,CFR 262.27(a)('d I am a Targe quantity generator)or(b)(d I am a small quantity generator)is hue. <br /> nerators mr ea ;pad Name <br /> n .r aigna re <br /> Month ear. <br /> 16.IM-M-unal Shipments <br /> r— ❑Import toU.S. ❑Export from U.S. `...Portof antrykwt . <br /> Z Tran r signature fore its only): Datelwil U.S.: <br /> w 17.Transpode,AdmoWedgment of Receipt of Materials <br /> Transporter 1 Primed y W Name <br /> ynature <br /> 2 on <br /> a ay ear <br /> y <br /> ¢ <br /> Transporter 2 PrinEeNfypW Name <br /> Signature Month nay Year <br /> 7A�emteFawdlly <br /> Space ❑ �anfity ❑Type ❑Residue ❑Partal Rejection ❑Full Rejection <br /> Manifest Reference Number:enerator) U.S.EPAID Number <br /> � fadli s Pl hone: <br /> W iBc,SignaofAlternate Fadlity(or Generator) <br /> Month Day Year <br /> Z <br /> ti19.Hazardous Neste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 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 hem 18a <br /> PnntedlTypetl Name SignaWre <br /> Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. <br />