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Sep 04 09 03: 20p Lindsay Schwager 2099523389 P. 10 <br /> ('12-pitch) ter. Form Approved OMB No.2050-0039 <br /> Please print w type.(Form designed for use on elhetypewriter.) <br /> enNumber 2,Page 1 of 3 ency EmergResponse Phone 4.Manifest Tracking Number, <br /> 1 Gmator ID G B F <br /> UNIFORM HAZARDOUS <br /> WASTE MANFEST `'' t.... <br /> 5.Gerer7 Name an <br /> Meting Address Generelofs Sile Address(if diflaenl than mailing address) <br /> Generator's Phone U'S47YA.z+Ff si il3d1g}�.n irh'e <br /> 6.TmrlsgQrlerat CorrtPan)f�lxrm r .- .vl+.-i.:.r .. a• <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name ' <br /> B.Desiyrated FadYty Name W4 Site Address U.$aEPA% = _i�.(-j i) . <br /> ..ori .M:.%i. ... . ... -.. .. <br /> Facill+sPhone: <br /> n Name.Hazard Class.ID Number. to.No Containers 11.Total 12.Unit 13.Wask Codes <br /> ya. 9b.U.S.DOT Description(including PropxShlppi 9 puaraity WLNd. <br /> HN1 and Pacting Group(if any)) No. TyPa <br /> all <br /> W 2 <br /> W � <br /> V' <br /> 0, <br /> 4. <br /> 14 SpOcial HBpolirr�Instmcbons and Additional lntormaaon <br /> 15. GENERATOR SIOFFEROR'S CERTIFICATION: he.Z,;;dare mal the contents of this consignment are fully and accurately described above by the groper shipping name,me andared I am thepackaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations,H export shipment and I am the Primary <br /> Exporter.I cortity that the contents of this consignment conform m the terms of dto attached EPAACknoWedgnrent of Consent. <br /> I certify that the Waste minimization statement idenlMed in 40 CFR 262.27(a)(h I am a large quantity generator)or(bl(til am a small quantity generator)is true. Month Day Year <br /> Generator's/OBeroSignature <br /> r's Printed/TYDed Name ( r <br /> _uI 16.International Shipments Import m U.S. ❑Billion Rom U.S. Pod of enhy/exic --- <br /> F Date leaving U.S.: <br /> Transporter signature(for exports only): <br /> 17.TmnswmrAclarovbedgmenlof R; iptof Matedals Month Oay Year <br /> w Signature <br /> p� Transporter 1 PnntedlTyped Name <br /> Transpprter2Pnnled/Typetl <br /> SignaNre.' x `; Momn Oay tax <br /> K <br /> r <br /> 10.Discrepancy <br /> 10a.Discrepancy Indicator Space 0 Quantity ❑Type Residue Partial Rejection Full Reaction <br /> Manifest Reference Number: <br /> EPA 10 Number <br /> r— <br /> a 18C.Nternate Facility(or Generator) <br /> J <br /> U <br /> LL Fatlfity's Phone: Month Day Year <br /> W <br /> 18c.Signature of Ntemele Facility(or Generator) <br /> 4 <br /> z <br /> 19.Hazardous Waste Report Management MelYroo Codes(i.e.,codes for hazardous waste Imalment,dlsDoseh and recycling systems) <br /> w2 3. d. <br /> 0 t. <br /> l20.Designated Facility Owner a Operator:Certification of receipt of hazardous materials cover by the m agthtueecaPl as noted in Item 10a Monte pay Vear <br /> Pdntedrryped Name <br /> EPA Form 0700-22(Rev.3-05) Previous editions are obsolete. <br /> 'OESIk'alOATED C--M.I L;iTYr TO GENERATOR ^a'.rATS IF P.'.IS0:P@Iti;��'; <br />