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Please print or type,(Form designed for use on elite(12-p. , ,ypewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man��at Tracking Number c� y <br /> WASTE MANIFEST A Fr 1 H 3 i V, !'o A 0. 9 -�tS:A� 4t -0-9300 8,lI yy g ;;a�d� .�J J J I� <br /> 5.GenemtofsN and ailingAadress <br /> �'a�`y.1)rt `t;;7i-T(iiit, Generators Site Address;(I different ban mailing address) <br /> Vat9 GS+frn gQ.rcV -dii`T.�]'ki IYC+SAWwl <br /> t. P'tHt1C i!: 7757? Tt7!` 1rA4 e:3 z i lif. <br /> Generators Phone: 41!) <br /> 6.TranspoMr 1 Company Name U.S.EPA ID Number <br /> r }13W pREp'tg.".P1u f'.d`1F1 '":-R'vIcix, C A 0 tD d ! to <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.DeslgnpMd FactlilY Name curd SAepddreas U.S.EPA IO Number <br /> fr{f MCI, <br /> p;,1v'l`t`atl" i'�.1�1 41R',flIT <br /> tri_[9t p PkOj rlllf; t;? '%TY3q C A T 0 0 A ,:> 4 ii 3 1 7 <br /> Fedl' sPhone: 6-,-1"P�y:-;T,I f-WI" <br /> 98. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Tell[ 12.Unit <br /> His and Pecking Group lB any)) IN Type Quantity WWOI. 13,Waste Codes <br /> 1. <br /> 2. <br /> t7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> at;r#tr I gr'2"91P'+il fi flogctoy" MIIS4�°PPkJNi4i919 7"APtl�Ci1Fi31Nirr n�.aia2rlV. <br /> rxa;l)9646'h9 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper snippig name,and ere disputed,packaged, <br /> marked and IabeledlplawNed,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 Pnmaiy <br /> Exporter,(.certify that the contents of this consignment conform to the terms of the attached EPAAcknowedgment of Consent. <br /> I canary that the waste minimUation statement identified in 40 CFR 21(if I am a large quantity,generator)or(b)(If I am a small quantity generator)is true. <br /> Genera rseOff mors Primet'ryped Name Signature J Month Day Year <br /> -a 16.International Shipments - <br /> F ❑ImpodN U.S. ❑E%Pod from U.S. Pod ofentiWeill: <br /> 2 Transporter sigrature(for exports only): Dela leaving U.S.: <br /> C V.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name 9 Signature Month Day Year <br /> Tcnsporter2Pdrtedrryped Name Signature - -` -- on Day -tier <br /> C <br /> s- <br /> } 1B.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity E]Type Residue ❑Partial Rejection ❑Full Rejactian <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> LL Facllilys Phone: <br /> 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e..codes Mr hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2, 3. 4. <br /> 20.Designated Facdhy,Owner or Operator Certification N receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> +II PnnNdRyped Name Signature Morth Day Year <br /> EPA Farre 5700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />