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4 t <br /> 0 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generefa ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trockmg Number <br /> WASTE MANIFEST ''I�-r' (I 'C C "1` 7.f_.'. I <,. o �i T f-, I, .. . f- <br /> s , ; u� —� � F � t r ,, ; ,4 FCE <br /> 5.Generators Name and Mailing Address - Generators Site Address(if different than mailing address) <br /> Generators Phone: Ji-'T - b y <br /> . rensporteri mpany Name U.S.EPA ID Number <br /> RECEIVED <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Ay 0 9 7017 <br /> B.Designated Facility Name and Site Addas U.S.EPA ID Number <br /> K.TF-1 1 J I?1 <br /> EiVVMEVMEN7ALHa•Tfid <br /> fi, d y r PEWIT�Ei4'�9:E9 A: <br /> n vr7,_ <br /> Facildys Phone: 2u C? ...?7d g p p Jj - - - - <br /> ga 91b.U.S.DOT Desumption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(i any)) 13.Waste Codes <br /> No. Type Quantity Wt./Vol. <br /> 0 htip i7C�Qj{ iY7i Y4Tl6r 41J .j E.ijhi .':qa..x <br /> w 2. i <br /> a. <br /> 4. <br /> i <br /> 4 Special Handling Instructions and Additional Information <br /> L f'i�lrt'1 Y/v��iL t'r(_r" :1 ,y6t+ C- (D,c�t D11.1•.� %A} t :it.; tb <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of Nis consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeled/placerded,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,('certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 We. <br /> Genemtors=erors PdrlWdRyped Name ignatum q� , on ay ear <br /> 16.Intemational3hipments - 2 ❑ � '•' i, <br /> 1— ❑Importto U:S. Export from U.S. Portb/entry/exit: <br /> Trans der si nature for exports only): Date leaving U.S.: <br /> w 17.TransponerAcknowledgment of Receipt of Materials J <br /> Tmnsponer7 PrintedlTyped Name bignature, 6tonth Day Year <br /> O <br /> zTransporter 2 Printed(Typed Name Signature,' ,y Month Day ear <br /> C <br /> F <br /> 18.Discrepancy `•/ <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> Q <br /> LL Facil' 's Phone: ' <br /> yOj 1Sc.Signature ofARemate Facility(or Generator) Month Day Year <br /> z <br /> z <br /> v- I.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> -/ 2. 3. 4. <br /> 20.Designated Facllity0w6er or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Nam -,� Signature �� Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. - DES1�xNATEO FACILITY TO GENERATOR STATE(IFREQUIRED) <br />