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. Md�ly pTs� <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone 4.Mandna Tmcking Numbe�rj /n'�GG `,C <br /> WASTE MANIFEST - - 1000 ! ^I.4 U v VES <br /> 5.Generators Name and Mailing Address Generators Site <br /> ite+A�d-dress(if Ulaitmailing address) <br /> R`CEIV` <br /> Generators Phone: <br /> 6.Transporter 1 Company Name JUL U 1 2015 U.S.EPA ID Number <br /> E7.T2nspoder 2 Company Name CN U S.EPA ID Number <br /> ___ 'Y4.ntblLorucNT <br /> 8.Desgna'ted Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone <br /> go, 9b.U.S.DOT Description(inducting Proper Shipping Name,Hazard Class,ID Number. 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity WI.NoI. <br /> 1.. <br /> p Q <br /> 2 oa i <br /> 3. <br /> i <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If expert shipment and I am the Primary <br /> Exporter.I cedily 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)(t I am a large quantity generates)or(b)(til am a small u ety generator)is true. <br /> Generators/Offerors PrinlesiTyped Name Signature / % Momh Day <br /> 6 1S Ye9f <br /> G� 2 <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Pod of entry/son: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrntedRYped Name Signature _ Month Day Year <br /> a -"� .. G i �ai <br /> N <br /> Trenspodar2Pngledr)yped Name - Signature (,, Malth Da,- Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Ouan ly Type Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> . Facility's Phone'. <br /> w 18c.Signature ofAltemate Fadlity(or Generator) Montt Day Year <br /> Q <br /> 2 <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> IJJ 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 1 Pnnte hyped Name Signature Month Day Year <br /> r <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNA IED FACILITY TO GENERATOR <br />