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..i <br /> For ,Approved.OMS No.2050-0039 <br /> ur type.(Form designed for use on eFte 12-pitch)typewntec) 2 Page 1 of 3.Emergency Response Plwne /.Manifest Trxklnp Number <br /> WASTE HAZARDOUS <br /> Ca aalalDNM�ar {�LF`-�. :' JJK <br /> WASTE MANIFEST Generators Site Address fol di8emm Man rrsiXrq edkess) <br /> 5.GeneralDes Name aro Mad'rtgAddress <br /> Casrstors Phare' U.S.EPA ID Number <br /> q , <br /> 6.Transporter I Compa'y Name <br /> � UA EPA IO Number <br /> 7.Transponar 2 Company Name <br /> U.S.EPA ID Number <br /> 8 p¢sgrsted Fadmy Name and Site Address <br /> Fadd s Perone10.Conlamers 11.TORI 12,Unit 13.Waste Codes <br /> ga. 9b.U.S.DOT DescnPlion including Proper Shippir9 Name,Hazard C .1D Number. No. Type Quantity Wtivol. <br /> HM and PaduN Group til aryl) <br /> O <br /> K i <br /> W <br /> e'I <br /> 3. <br /> td.Speaat forming InSlmdions arts Additional blanmdon <br /> 15. GENERA TOR'SIOFFEROR'S CERTIFICATR1N: Thereby faders Mat to cadenls clove consignment are M1dfyy and xwretety damped above by the PWer sMppbg name,sol me dessitied,packaged, <br /> narked and IabaleNplacartled,and are b al respects M MWcDndiUan br transport eccmding to appkable intemaDb land national govemmenhl mguMlbrrs.II export shipnsnl and am ere Pruns.y <br /> Exporter,I Di that to contents of tis consigrunent confirm to the tem of the attached EPA ACknowisdgment of Consent <br /> I cs.tily Mat Me wastem.WkaWn statemem identified M 4C CFR 263 27(a)le I am a tenle quantity generator)or(b)(if I am a smal quanty generaI00 a true. .._ Mpmh Day Year <br /> GanaralarslOiMWS Printacl yped Name Signalure <br /> 16.Intematiorsl ShOWN ❑Import b U S. ❑Export from U.S. Pod of enby7exil <br /> f— Date leaving U.S.: <br /> Transporter signature(for exports myy)'. <br /> u7 17.Transports.AdmmNe gTwg of Retest of Materials Month pay Year <br /> Torry s.1 PmtWyped Nmrre Signature <br /> O <br /> Q- Mont Day Vem <br /> Zgnature <br /> Transporter 2 PrkaedlTyped Name 5! <br /> 4 <br /> K <br /> r- <br /> i18.Orcrepency <br /> Itis.D wspr tcY Indication Space ❑ ouanfity ❑TY, ❑Residue ❑Paniai Rejection ❑FUN Rejection <br /> M,ouesl Reference Number. <br /> 18b.Altemas Factry(or Generalor) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facipty's Phare: Mont Day Year <br /> 4w 18c.SgmVe of Atemahe Facility(or Generator) <br /> Y <br /> 19.Hazardous Wasre Repot Alanagemenl Method Codes(i.e..tales for naxartlws waste bealmenl.tlisposal,and recycling rystems) <br /> 4. <br /> o ' <br /> 20.Desgasd Fadkty0vne a Olxralor'C triion o(receipt of hazards maters Avs.ed bye manifest except m nded n Ihrn 18a Monts pay YewPm yped Name Signature <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. CENEF1ATO WR INITIAL COPY <br />