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Please <br /> not or type. Form de ned for use on elite(12-pitch)typewriter.) Form Approved,OMB No.20500039 <br /> UNIFORM HAZARDOUS L.Generator ID Number 2.Page 101 3.Emergency Resprnsa Phone 4.M}}a"'n�}N{{ayyst rack�i*ng Numbs�r';pp t g� <br /> WASTE MANIFEST '. - •' i:•4^ V 61 L:2 n:„J33 J(S <br /> 5.Generator's Norms and Mail ng Address Gerwra oes Site Address(H different than mailing address) <br /> Generators Phore: <br /> 6.Transporter t Company Name U.S.EPA 7D Numbgqerryry„„ qqyyqq{{+t. <br /> 7.hanspodar 2 Crompany Name U.S.EPA ID Number <br /> B.Designated Fadltty No Sae Address <br /> U.S EPA ID Number <br /> Fadtdy's Planner.: <br /> ge, Sb.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number. 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(i!any)) <br /> 13.Waste Codes <br /> No. Type Ouandty MaNfol. <br /> z <br /> Z. <br /> t <br /> 3. <br /> 4. <br /> 14 IHemlling lnstrucnoasandAdd,tonakin tbn -- <br /> f v <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this eonsignmerd are My and accurately described above by the proper shipping name,and are classified,padketi <br /> marked and laboled1placarded,and are in ad respects in proper condition for transport according to applicable international and national timemmental regulations.If expert shipment and I am the Primary <br /> Fxporta,I ce(14 that the cements of this consignment conform to me arms of the attached EPAAcJuroMaOgrtrent of Consent, <br /> I certify that me waste minimization statement identified in 40 CFR 262.27(a)(H I am a large quardity Pollan r)u(b)(ffI am a smell quantity geirnmend is tore. <br /> GerceretodefOtteroys Pnnta47TypaQ None s Sigrralure `aaur^"+m"^^�^^�--....,.,,� Day Year <br /> 16.Intema6ona1SNMmts <br /> Z <br /> ❑import to lJ.S. ❑Export tuna US. Port of eery/edC,�_ <br /> Transporter signature(fa exports only): Date leaving U.S., <br /> IX 17 TranswrterAdmoMadgment of Receipt of Materials <br /> TrenSporQpt 1 Pdnmit typed Name i nalem 0M 4w, <br /> op <br /> , <br /> . Tranaporter 2 PnnteNTyped Name Signature Y Month Da yew <br /> y <br /> } 18.Discrepancy <br /> las.Dr&repancy indication Space ❑ Wantly ❑Type EIRasitlUe <br /> ❑Partial Rajeclon F]Ful Rejection <br /> Manifest Reference Numbsc <br /> 181d.Alternate Facility(or Generetor) - U.S.FPA ID Number <br /> U <br /> sa+- Facility's Phone: -- <br /> w i 8c.Signature cafAdtannale Facility(m Generator) <br /> d MonthDeg Year <br /> sc JUN -el B cu1Z <br /> 19.Hazardous Waste Report Mar"amant McNrod Codes dav,codes for hazardous waste treaMent disposal,and recycling systems) <br /> 1 20.Designated FacBiy O+mera Operate:Cenahcataal orreceipt ofnazardous materials manifaeCeltCept meted in item l>M' <br /> Printedifyiped Nam Signature Monts Day r <br /> EPA Form 8700-22(Rev.3-05) Previous ediAons are obsolete. GENERATOR'S INITIAL COf _ <br />