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Please print or type.(Form designed for use orr elite(12-pitch ' .) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GeneratarlD Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST i:CJ..'"..3.40_9u�z!c'�h'2'i 1 .Ff,iiil..t_(:f;_..? ;rt',,:.13r i <br /> J31,_ --483 FLE <br /> 5.Generators Ram and Mailing Address Generators Site Address(i different than mailing address) <br /> "I ;_., ,,: RECEIVED <br /> Generators Phone: G`�ifri mit'_ --'15 14 <br /> 6.Transporter 1 Company Nam - U. . P ID um <br /> aolg <br /> :RP ui _r{i ._f'IN :YSi 2`.-�y T`:;i&u:tto,4+::� <br /> 7.trisporter 2Company Nare ERMIT/SER!V61 <br /> B.Designated Facility Name and Site Address r ( LLS.EPA ID Number " <br /> I1 ,MILES S [TF Rt:ATV ii'r1Y ,5 <br /> BEATTY a N I P-w--1- <br /> (.{ 1. t_ .;c)...,5�3-�a..°, ;u�'}J74�'1n44'<I <br /> Facility's Phone: <br /> gra, 96.U.S.DOT Description(mdudi g Proper.Shippkg Name,Hemrd Bees,ID Nuenber, 10.Con is _ 11.Total 12.Uni{ 13.Waste Codes <br /> HM and Padang Group(If airy)) No. Typo Quantity W11Vd. <br /> n_' 1 !'%tiff ni.rtt t'147 ,t '[)US WA:711' RO..IXI DYN 352 - <br /> o rFI?frMDP411A MAGEst if SEPI ERANT WL <br /> Q5 <br /> AND R'3 IRPEN T, ~ <br /> w <br /> w 2 fiJC1� RL'RG HAZARDOUS WETE LIQUIDS ,,=+*- P c!91 <br /> i)�(sE.ik,Qf PAINT 'MRSTE, IN MG) <br /> 3. ! <br /> �µ <br /> 4. <br /> 14,Special Handling Instructions and Additional Information <br /> .srs t: 1IF{'e.'2:c.31+&�ikls •r�rc�t..:ryr ..c 7411,7 <br /> m <br /> iiR I p1r"41G��IIi,Y #F1 qct;—utafl j :. F9 (C'1111}f t :lE"n <br /> X971 TCl X:S fQT!1f ! Tf�_hf'-,+`-17 l r.trlk 4C-h i GAtti L.dC nc, hfr- `t='"-" Chp./ <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and latmed/placarded,and are in all respects In proper condition for transport according to applicable international and naflonal governmental regulations.a export shipment and I am the Pnmary <br /> Exporter,I certify,that the contents of this consignment conform to the temms of the atlached EPAAcknoMedgment of Consent <br /> I ceNfy that the waste minimization statementidentified in 40 CFR 26227(a)(d I am a large quantity genemtoavi(b)(ff I am a small quantity generator)is true. <br /> Geneators/ mrs d Na <br /> Pnn!!!ypeme ,, " ignatu ,-, on ay Year <br /> rf avt C: <br /> 16.International Shipments <br /> F ❑hnpmt to U.S. - ❑Export from U.S. Port of entry/exit <br /> Trans der si nature for exuorh only): Date leaving U.S.: <br /> 17.TransponerAcknoMedgment of Receipt{of,l Materials <br /> C Transpd Rntedriyped Name % <br /> gnature - n 11 . ay Year <br /> I T iw . )/ <br /> 1. <br /> QTransporter 2 Printecirryped Name gealure -_ Month y Year <br /> K <br /> H <br /> 18.Discrepancy <br /> r the.Discrepancy Indication Space ❑ Qua Residue j <br /> Nity El ❑ El Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL <br /> Facilitys Phone: <br /> W16c.Signature ofAltemate Facility(or Generator) - _ Month Day Year <br /> Q <br /> Z - <br /> h19.Hazardous Waste Repot Managemfent Method Codes(i.e.,codes for hazardous vaste mad ment,dsposal,and recycling systems) <br /> 0 1. 2 3. 4. <br /> 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the mandest except as noted in Item ISo <br /> Pnmktl/fyped Name Signature Month Day Year <br /> EPA Forth 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />