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Jul 21 15 12:03p DELL 2QQm"r6-0677 p.5 <br /> I fw ir . CIV\ j-'-I �O <br /> Please print 1a type.(FDim designed far use on elite(1&pitdl)type'wrt:ec) Farm Approved.OMB N0.2050-0039 <br /> UNIFORM HAZARDOUS I 1.Generator l0 Number I 2.Page 1 of 3,Fi7ergency Response Phare 4.Manilas!Tracking Number <br /> WASTE MANIFEST _ ` _ ;+P >e�rry ^ 't •:jVES <br /> 5.Geremlcfs New and MairingAddress Ge:emtrYs SleArld ass if diferem than maling address) <br /> Genamtors Phony ` . _._..._. . <br /> a.Transporter 1 Company Name US.ERA ID Number <br /> 7.Trmamer2 Company Name ' U.S.EPA ID Numbs <br /> B.Deaigread Fadlfy Name and EkAddreea,... U.S.EPA DNwtw <br /> Faclttys Phme: <br /> ga. <br /> 9b.U.S.DOT Desc*1onikxluMng Inmov ShopingName,Hazard Clang lb NuMer, 10,Comalars 11.Trial 12.U.dl .. <br /> HM ed Packing Group llfatry)} NO. Type Ouartlty YdNd. 73.W20 Codas <br /> _ r <br /> W <br /> Z 2. <br /> 3. <br /> A. <br /> 14.Special Handling hatwdbm endrddf anald1mrnadon <br /> 15. GENERATOR'SIOFFERORSCERTIFTCATIDN: IherebydeOarema:tle cemams of the consignment am'ully and accurately despI above by the proper Shipping new,Ord are classified,packaged, <br /> marked and lateleciplararded,and am r all respects in proper mndtion for transport asardng to applicaNe inerrembrel end nagond omendwrial*90131 ria.If export shipment and I an the Primary <br /> EVorter,I ce•tlN that*a remade of this cereigmerd scalars In the tarns of the aaeched EPAAckrovAedgmer4 of Coward. <br /> I certify Nat the wash mininizstiea sb!ement idartiflad In 40 CFR 26227(a)(f I am a large quantity goxreto)a @)(11 an asmall quantity generators is two. <br /> Genamtas101femrs PHmedrTyped New I °signature Nam NF Tear <br /> 1, - <br /> 18.Inbrneaonal5hlpm¢nN <br /> ❑rnpodb U.S. ❑FFxportirom U.S. Pert oferdryyext <br /> Transporter sgretura:for exports anti): Date leaving U.S.: <br /> 17.TratspoderAdo wledgment of Receipt at Materiels <br /> CTransports'l hinted`Typed Name SigraWre Month Day Year <br /> O <br /> w <br /> aZ Tansporter2 PrinterYfyped Name Bpnalum Month Day Yea <br /> Discrepancy <br /> iSa Dla[repanry n3am on Saace Q..", ❑Type ❑Reefte ❑Partial Rejection ❑Full Rojecam <br /> Nanfest Rawarce Number. <br /> 106.Alternate Facfly(or Generelari U.S.EPA 10 Number <br /> 7 <br /> V <br /> < Feclliy's Phone: <br /> W 19u Slgnebue o(Alefrate Facility(or Gerrarala) Money Day Year <br /> a <br /> z <br /> y '9.H¢e8rden9 waas RepM MaregeMm Melhad Code$Ii.e,owes fornerardous waste teebnanl,disposal,am ecycksi sysams) <br /> LU 1. 2. 3 4. <br /> 1 20.Designated Facility ONVOr Operator CadIcedon of mceiptd fatardam maledials mremd by the madesl ezaptas:lad m Item!Be <br /> iroladIlyped Now Sigralum Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous edhonsare absolate. GENERATOR'S INITIAL COPY <br />