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<br /> Please print or(ype:Form:designedfor,use on stile(2•Itefa)typeWrter. 1 Form Approved.OMB-No.,2050-0639
<br /> UNIFORM HAZARDOUS 1.Generator ID N17in�er r ' 2.Page 1 of 3.Emergency Response Phone 4.,Manifest Tracking N'u�mbgr`
<br /> WASTE MANIFEST ;tet''! O+H1.37 165-D) f @�i/1r4��ra�{cl . , . ��3 3&P'�3:S JJK
<br /> S.Generator s Name and Ma111ndAddrass Generator's Site Address Qf dl8erentdhan mailing address)
<br /> ALCOIF+JN.MAE'(AMAID
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<br /> 6,Jrans,�o001 Congiany Name' U.S.EPA ID Number
<br /> ENVIR>!r'�>:�r�TA f c�s!t rrf bt F+�fiuf"f liliC.. c:A�.O L� t t18 2 0
<br /> 7.Transporter-2 Company Name U.S.EPA ID Number
<br /> 8:Designated Facility Name and Site Address U.S.EPA ID Number
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<br /> Fecililys Phone: f77L "`•5 •�2!)3 I)v T3 a a a 9 Q 0 a G-
<br /> ga• 9b.U.S.DQT Qescriptfoq(including Proper Shipping Name,Hazard.Class,ID Number,,: ..10,.ContafnBra. 11.Total 12,Wit 13.Waste C
<br /> HM and Paddng Group(ifany)) No. Type' Quantity WLIVd. odes
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<br /> " 14:Spocial Handling InstrucUons'andAddltionafinfdrinalloh
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<br /> 24 HIR PP�rLldlv(?N .Y i lQ� k75Ers4r
<br /> iG 'GENERATOR'SfOFFEROR'S CERTIFICAT16Ni 1 hereby declare that the content§.bf thfirconsignment are fully and accurately described ebove.bylh0 propershlpping name,and are classified,packaged,,
<br /> marked end Iabeledlpieoarded,and era in all respells In proper condition for transport accgrding to applicable International and nalionai povemme t a I po dam the Pdmary
<br /> -Exporter,I ceitifythat Ind dbntents of thls donsfgnment conform to the terms of th'e'attached EPAAcknowledgment of Consent. KtA�
<br /> I certify that the waste minfmizatibn statement identified in 40'OFR 26ZV(a)(If f am;a large quantity gdnerator)or(b).Qf l am a'mall clan }, •T
<br /> Generatoes(Offeror's Pdntedfryped Name'•' Signature.' Month Da Year
<br /> 16.International Shipments
<br /> :..
<br /> ❑Import tour.-- '' ElExport from U,S. Part of erilry/exit: '
<br /> Transporter signature(forexports only): Data laevindU:5
<br /> 17.Transpo erAcknowledgmentof.)teceiptOfMeterfafs'' • ...'01is
<br /> aTransporter 1 PdntedlTyped Nam' "'+' Signature,± ,? , Month Day Year'
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<br /> pa TdRtN ' Month-. Day 'Yeaf.,.
<br /> 1Be,Discrepancy Indication Space- •❑Quanti "'"❑T ❑Residue
<br /> ty ypd: ❑ParUal Rejection ❑Full Rejection
<br /> ManlfestRafererrce Numher.• '
<br /> 18b,Ai[emate Facfllty(of Generator ;;r" U.S.EPA ID Number
<br /> .a Faclliljrs'Phorie:`
<br /> G 18r.SighiOre ofAllbmatd Fadiiily(or Geherafo'o - Month Day .•Year'
<br /> 71
<br /> Z r:.•
<br /> '. �;:18.Hs?ardous Waste Report Manegemenf Method Codes(I,e.,codaelorhazerdous.waste tretltmenl disposal,-and racycling.syslems). . . ,
<br /> G 1. 2. 3. 4.
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<br /> signated Facility Owner or Operator.Certification of receipt of hazardous materials coveredby the maniresfexobpfes'noted Initer il6a
<br /> ffypad Name Signature Month Day Year.
<br /> EPAForm 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'SIN 14L.'COPY
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