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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.C�ePer�oc(,D Nym r 2.Pa 1 of 3. M e envy Rr�mpa Phi 4.Maniffeest Tmckfn Number s� <br /> WASTE MANIFEST G. /lf% (�f o I�SS(O //ll��--C� 01 08 527x9 JJK <br /> S.Gene�WtsJ� and/titryling[WLCC srs/$i���repss(rf dift¢/eNeOtnmailingad ess) <br /> Cys L' // `/JGI r (�� S <br /> atoe <br /> Generator's Phone: y ,�'Oq) -7`7 Ll_5-00 <br /> 6.Transporters Compayle Re 61714 PAIgNulByer� <br /> 7.Trans pyfhfy Cggipany Ne�me. �Y \/r,,J U.S.EPAIDNomibeyr/) 7 <br /> B.Desig pilityfyaUne and Site ss &r ,r ,�Y „l_ ,J U.S.EPA ID Number <br /> �J( <br /> s ° 533 Phone. <br /> Fa (408)yy/-a 9rvail s� 9�1 / <br /> plltys <br /> ga, 96.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Gmup(d any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> O <br /> K <br /> 2 2 <br /> W <br /> (l / <br /> 3. <br /> 4. <br /> 4.Spedal Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROWS 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 Iabeledlplacarded,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 Primary <br /> Exporter,I earthly 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 quantity generator)is true. <br /> GeneratolslORerors Printed/Typed Name Signature Monti Day Year <br /> �j 16.Intemabonal Shipments <br /> Z ❑Import to U.S. ❑Expod from U.S. Pod of entry/exit: <br /> Transporter signature(for expods only): Date leaving U.S.: <br /> W 17.TranspoderAcknovAedgment of Receipt of Materials <br /> Transpoder 1 PrintedlTyped Name Signature Month Day Year <br /> p <br /> a <br /> N <br /> QTransporter 2 PrintedlTyped Name Signature Month Day Year <br /> K <br /> r— <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Refe ce <br /> 18b.Alternate Facility(or Generator) q <br /> J_ <br /> V <br /> rai Facility's Phone: '{ <br /> w 1Be.Signature of Alternate Facility Generator) Month Day Year <br /> ti I <br /> E. VIS <br /> 1.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste beebnent,disposal,and recycling systems) Pi3`Mr'ES <br /> G 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.CeNfication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnntedrfyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />