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III IIII I!i II I Iillll(II II!I III I IIIIIII� <br /> Please print or type.(Form designed for use on elite(12-pi*ewriterJ Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generalor ID Number 2.Page 1 of 3,EmergencyResponse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST - - - - - 000543348 VES <br /> 5.Generators Name and Mailing Address Generators Site Address(N different than mailing address) <br /> C7 - <br /> Geneators Pdlan@: <br /> 8.Transporter 1 Company Name LLS;EPAID Number <br /> 7 Transposer 2 Company Name ~ U.S.EPA ID Number <br /> 8.Designated Facility Name and Site AddressU.S.EPA ID Number <br /> TEt_'n1 o i __LJ moi? <br /> Facililys Phone. - - - <br /> 9a 9b,U.S DOTD%c6ption(including Proper Shipping Name,Hazard Class,ID Number. 10.Containers 11.Toad 12.Unit 13.Waste Codes <br /> HM and Packing Group In any)) I, Type Otanilty Wt Not. <br /> 0 <br /> Z 2. <br /> w <br /> 3. <br /> 4 <br /> 14,Special Handling Instructions and Additional Inform ton <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION'. I herebydeclare lhel the carteasofthismndgnment arefully and accurately described above by the proper shipping nam.and aredasslfied.packaged, <br /> marked and labeled,placarded,and are mart respects o proper condition for transport according to applicable memationala ld norm al governmental regulations.If l xpoR shipment and I am the Primary <br /> Exporter,I cemifp that the contents of this consignment ccnfomh to the terms of the attached EPAAcknovdedgment of Consent. <br /> I cYRily that the waste m ramizabon satement identdied in 40 CFR 252.27(a)lit I am a large quarmly generator)or(b)(d I am a small quantity generator)is We. <br /> GeneralorsrOflerors PnnleoTypetl Name Signature Moth Day Year <br /> -7n [41 <br /> J 16.international Shipments <br /> F <br /> 13 Import to S. ❑Export from U,S. Pot of entry/exit ---- <br /> Transporter signature ifor exports only)', Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of htalenals <br /> 1- Transporter I Pnnto&7ypad Name Signature Month Day Year <br /> u <br /> Transporter 2 Pnnled.Yyped Name Sgreture Month Day Year <br /> 18.Discrepancy <br /> 18a.Disrremrcy Indication Spam ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> F I8b.Alternate Fadily for Geneetorl U.S.EPA ID Number <br /> J_ <br /> V <br /> ra Faulity's PhoneYear <br /> w 18c.5ignadure of Alternate Facility(or Generator) Month Day <br /> a <br /> z <br /> N19.Hazardous Waste Repoli Management Method Codas(he.,codesior hazardous waste treatment,disposal,and recycling systems) <br /> 2 3, 4. <br /> 20.Designated Family Owner or Operator.Cerrurcabon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Tped Na S le Monty Day '(ear <br /> Pn <br /> y <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />