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Please print or type.(Form designed for use on elhe 12-ptch)typwritarl <br /> UNIFORM lIAZARDOUS t.G.m,mmr ID Number 2 Pee 1 of 3.Emergency Rea Form Approved.OMB No.2050.003 <br /> WASTE MANIFEST C`kQ=aM g 0 P° Phone 4.Manilas)Tracking Number_ <br /> Bret EC;c,P'- Fre 4 r�r JJK <br /> S.Generetols Nameand MatlingA u'ess 0 11-r i is�9 907, <br /> .csi3e'f r f;:ktie"7 iJR Genemmrs Sim Atltlress(i1-1-1.M Nan mailing atldreas) <br /> i09aaui9r Wig)Di Woo(�hcfnn>, <br /> SIC+fi1.fCNk.CA5529k 1010 hy*utie'.L <br /> GeneratcYs Phone: 200 S"fl-If 15e., w�.F"3T.1.^vSt;.. <br /> 6.Transporter 1 Company Name <br /> Iri �nN6ia C1s�gf�' 9Ft,:fii-euudst FF.M BSeSaFrdt2F u.s.EPA IDrrunaer <br /> 7.Transporter Company Name C„a772unli <br /> 41a➢(�LiPo'd i tone g4{y!$q{y ODz U.S.EPA ID N mber <br /> 6.Desi N fac('iv Nam antl Site Address LAS1s2ii234:S3 <br /> U.S.EPA ID Number <br /> £s=.rte kC,l'88b.9J <br /> FadiPhone: <br /> ga, gbU.S.DOT Desaintmhinduding Proper Shipping Name,Heard Class,ID Number. <br /> HM and PaUa1g Group(d any)) 10.Containers H.Total 12.Unit <br /> No. U,pI. 13.Waste Codes <br /> Type Quantity W <br /> C f' ��4i��.��:& 9sdfOUH✓timk:MJ.'�4 rC.`"{a%O�r�1�lOC}19pifiC Bgr'}j d <br /> /r� ra <br /> z 2. — <br /> W <br /> 3. <br /> 9 <br /> 4. 1 <br /> 14 Special Handling instructors endAUditianal lmormatioq, <br /> srw."VO4fi9 05254 Sef±f;Ofdor ;%56 <br /> + ' a?oiz7seta Dr�rErar�; e sr E� , �e1I - 1'jcfr Are , <br /> 75. GENERATOR'S/OFFEc riled CERTIFlCgTHIN:)hereby declare)hal the mnlents olmis wnsignmantare(ally and eraremly tlesmbetl above try I propmshlpping name,and are UaesNetl,packaged, <br /> marked and IabaleNplacaNed,end ere in all respects m pmperaondition for transport according to applicable fr ematiomland wrional governmental regulators.If e <br /> Exporter,I ceNfy that the contents of this consignment wnfm m the terms of the attached EPA Acknowledgmentof Consent. wort shipment and I am the Primary <br /> I(edify that the waste minimamion statement idankled In 40 CFR 262.27(a)Of I am a large quantity generator)or(b)(R1 am a small quaintly generemr)is he, <br /> GenerabrWillem rs PantedrTypedName, Sigrrature- <br /> i yid /`fie-4'dct- e � [�_- f Month Day Year <br /> F 76,OmaneWnal Shipments <br /> El Nlpon to U.S. ❑Export nom U.S. PW of entry/exit <br /> m Transponder signature(for exports only) <br /> K 7.Turns rterAckrwwl p Date leaving U.S.: <br /> 1 <br /> w po edgmeM of Recti toF Materials <br /> K Transporter 1 PPoaed/Typed Nem /� tor <br /> f b Ne d Signature � f.�� .� e Month Day Year <br /> 2 Trans ((Prin Name 4n r'4r k F G'@✓ e. ' r m" I <br /> Z SOna�re ,!j�f Monty Dox...Year <br /> / , <br /> 1 16 Discrepancy <br /> I 18a.Discaepancylndomion Space ❑I Qusnafy - ❑Type ❑Residue ❑Perlia)Rejection ❑Full Rejection <br /> 186.Almmate Fauth,for Generemr) r4anAeM Reference Number: <br /> —t U.S.EPq 10 Number <br /> U <br /> n Facillys Phone <br /> 18c.Signature cfAtemate Facility(or Gewmmr) <br /> 2 Morrm Day Year <br /> ry19 Naz us she Report Management Method Codes(i.e..codes for haaallous waste <br /> ' treaNrent,disposal,arm recycling systems) <br /> oF 'f z. <br /> (.• � 3' 4. <br /> 1 20Designated Fsalry Owneror Operetor Certttimtonofmmpto ousmale zls oeredRy me marl asaceps as MedN em l8a <br /> Ptlmed/Typed Name <br /> Moret, Dal'. lyfas, <br /> EPA Form 8700-22(Rev.3-05) Prevwus editi0nsarecbsolete. �� c � ������ / � �p '�a° <br /> �' DESIGNATED FACILITY TO GENERATOR <br />