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lease print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-Mg <br /> UNIFORM HAZARDOUS 7Ger*-t0rID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST Z !!uj O D / _ JJ K <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ,Z-/?-- L sr <br /> STiGIfTo�`' eq <br /> Generators Phone `/wo ` -er R i <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address /e-/-I e "VV-PW 6 G U.S.EPA ID Number <br /> /I S/5-Y- A✓r//T/ K <br /> 21r</to -,q ys ;,-y L <br /> Facility's Phone:61& -Q 6-e, C b <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit <br /> Q.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity WWoI. <br /> o oaVs 4,X, 572 L✓G��d�oi q uN L <br /> z 2. <br /> W <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information <br /> 95-1 <br /> 813534 9q: <br /> 15. GENERATOR'S/OFFEROR'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 labeled/placarded,and are in all respects In proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offerors PrintaWyped Name Signature Month Day Year <br /> d <br /> -j 1 16.Internaboagi Shipme is <br /> F E]Import `` f <br /> Import to U.S. Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> 1 Transporter 1 Printed/Typed Name Signature Month Day Year <br /> ac 9 ��U <br /> N <br /> Za Transporter 2 Printedrryped Name re Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> kat Facilitys Phone: <br /> W1&.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or gperubwCerbfication of receipt of hazardous materials covered by the man t except as noted in I 1 <br /> Printed/T Name. Sig lu a Month Day Year <br /> L <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 00005.0363 <br />