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Pleaseprint or Mx.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.P- e I of 3.Erna envy Response Phone 4.Manifest TrackNN"6'1b�47 FLE <br /> WASTE MANIFEST � .1{— �. <br /> 'I �-- � ' ' r 7-1�1 <br /> -Pa <br /> "T <br /> 5."op Name arx];Moiqlpq-4,Iidress- Generators She Address(if different than mailing address) <br /> E <br /> Generator's Phone: I <br /> 6.Transporter 1 Company Name w r ti U.S.EPA ID Number <br /> I r <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Name and Site Address U.S.EPA ID Number <br /> tilt <br /> Aj r <br /> -7 <br /> Ic <br /> Facilitys Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 10 <br /> Z 2. <br /> LU <br /> ILD <br /> 3. <br /> 4. <br /> 14.SpeciakI.Handling lostructions an <br /> I I : . p Additional Information C7, <br /> 1 ) <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare 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/placarded,and are in all respects in proper condition for transport according to applicable international and national govemmental 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)(I I am a small quantity generator)is true. <br /> GeoeraloestOfferors tedIT",Name bignature j M�* Day ear <br /> -1 16.lntematk)nal Shipments <br /> ElImport toU.S. E]Export from U.S. Port of entry/exft: <br /> Z Transporter signature for exports only): Date leaving U.S.: <br /> tu IT.Transporter Acknowledgment of Receipt of Materials <br /> JX <br /> P- T" 1 <br /> ' 1 Prinledffyped Namt- ----7ignaru—re f onth Day Year <br /> CL <br /> 0 T!1 <br /> U) <br /> Z Transporter 2 Printed/Typed Nam bignature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 0 Quantity L1 Type ❑R�,idu, El P,rtJ,I Rje,tion Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> L) <br /> W Facility's Phone: <br /> C3 <br /> LL, 18c.Signature of Alternate Facility(or Generator) Month DayYear <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ 1 <br /> 1 2- 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />