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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.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackkiin umber Cc <br /> WASTE MANIFEST - n 0 0 5 ')L.L 'J VES <br /> 5.Generators Name and Mailing Address Generators Site Address(f different than mailing address) <br /> DBA GA.CTIV LLC. <br /> . 4_54_5 Ol1A_t!TA_r. I N. <br /> Generators Phone: <br /> 6.Transporter 1 Company NameS.EPA ID Number <br /> RECEIVE <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ENVIRONMENTAL <br /> IJC ArTV r1COA OTAdCNIT - - <br /> Fecili s Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.ContainersType 11.Total 12.Unit13Waste Codes <br /> HM and Padding Group(if anyp No. Quantity Wt.Not. . <br /> 1. <br /> K <br /> O <br /> s <br /> Z Z. <br /> W <br /> c9 <br /> 3. <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 labeledlgacarded.and are in all respects in proper condifimr for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I candy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I candy that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity,generator)or(b)(if I am a small quantity generator)is true. <br /> G2neretorslDferers Printedrryped Name Signature Month Day Year <br /> Vii. s <br /> 16.Intemafonal Shipments H <br /> F ❑Import to U.S. ❑Export from U.S. Pod of entry/exit: <br /> Transporter signature(for exports only(: Date leaving U.S'. <br /> w 17.TransporterAdmovtedgmenl of Receipt of Materials <br /> Transporter 1 PrintedRyped Name Signature Month Day Year <br /> N <br /> Z Transporter 2 Printed/Typed Name SignaMe Month Day Year <br /> K <br /> 1-- <br /> } 18.Discrepancy <br /> 18e.Discrepancy Intlicatlon Space ❑ Quantity ❑Type El Residue ❑PaNal RejectlonEl Full Rejection <br /> Manifest Reference Number: <br /> 18b Alternate Facility(or Generl U.S.EPA ID Number <br /> J <br /> U <br /> n Faciliy's Phone. <br /> 78c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous wade treatment,disposal.and recycling systems) <br /> t. 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 154 <br /> Printecirryped Name Signature e,- Mool, 6W-7w—r— <br /> Ir <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITYTO GENERATOR <br />