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Please print or type.(Form designed for use on elite(12-piiwriler.) Fen Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number f r +AT) i t 2Page;1 of EerPhg <br /> WASTE MANIFEST r�C, 4.M 6ott g903 <br /> 76 FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Wine GrQ. . int: f >� <br /> 1 ialaal <br /> T ONtis -J5 L#:. ? >i l.'.••-.`cs>4 <br /> Generators Phone: t=Ou. 4111 <br /> I. ransporterrl. oT°K.r.f.No 5Y9TEA!S, TIe4':', 01u.qnDislumber <br /> 7.Transporter 2 Company Name Q7EPA ID Number <br /> S.Designated Facility Name and Site Address :v.-e•A{6 HOH U S 6 rtl to L,i_0W' L', U.S.EPA ID Number <br /> E.51'W L.DyKERN ROAD . <br /> BUTTONtti1TL1_014 <br /> 5ei%"•i'6=-f,cNtkT {,.:«Y;"7Atgc�lic.jr, <br /> Facili 's Phone: <br /> go. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Pacldng Group if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> WOW NON OCR61 t RZs;kstDt i S WA a E L.WAJ i tPf <br /> F (ii�t. Slt1f?F.r SAND W07 P). #'a r1 ) <br /> cow,• aQ ClLxjl' �"` '...:� <br /> M 2' 'y.-+C G er'n-fes_ .•. .r.G s-�-1t- <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information t c-y, y .;)t Ft fi-! W 1 i u•3.-. <br /> t�� Hi? EMPRGENC'Y 1#1-1500-46A-176121 (Mk t 'I T) <br /> Par 63x7 <br /> Ti, 00 `AGENT-f-0R"' ICY REN TO RF.�'.PIN l.IF„rd_:�'C> AIS- CARRtFRS fit <br /> 7a 1'31 .1 <br /> 15. GENERATOR'SIOFFEROR'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 governmental regulators.If export shipment and I am the Primary <br /> Exporter,l 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)(if I am a small quanfity generator)is true. <br /> Generators/Offerors dntedfTyped Name ignature Month 33y__rea_r <br /> 16.International Shipments <br /> z Import to U.S. ❑ port from U.S. Pod of entrylexit: <br /> Transporter signature for exports onl ❑ Ex <br /> Date leaving U.S.: <br /> w 17.TmnsporterAcknowledgment of Receipt of Materials <br /> E2 Transporter 1 Pdnted/Typed Name signature j - Month ay ear <br /> QTrensporter2 Printed/Typed Namegnadure Mont Day ear <br /> C <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity El Type ❑Residue ❑Panial Rejection ElFull Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility for Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL <br /> Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Cer ification of receipt of hazardous materials covered by the manifest except as noted in Item led <br /> PdntedrTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />