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Please print ortype-(Farm designed for use on elite(12- 'tch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•cGe�• afor(D Num r 2..Page 1 of 3.Emergifest ency Response Phone 4.ManTracking Number <br /> WASTE MANIFEST JJ K <br /> 5.Generator's Name and Mailing Address \rk I Generator's Sile Address(If clifferent than mailing address) <br /> (,' - . '.i' •I•,°'t"+r:.,. �rpi?f� �'(• .:;a yr.4`�-r:. ._ re:f•,,�.-A'w <br /> Generators Phone'f' ". <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> a.,1r .. Env'•at;is rivi:3i-+:pct_ -;L-t o:':y t r'J 1:};• <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> r <br /> 8.DesgnateclFacilltyNameand Site Address T=�M;j;•I;;f '?':r!.-S U.SEPAIDNumber <br /> 44�>)"",F",•e:F;''t6:i.7'"!,.;�} .,st•'s.•LL'<..:1i^\ <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description Q-cluding Proper SNpping Name,Hazard Class,ID Number. W.Ccntalners 11.Total 12.Unit <br /> HM and Packing Group(if any)) 3.Waste Codes <br /> _ Na Type Quantity W!Nol. <br /> 7777 <br /> 0 7i <br /> z 2.LLJ <br /> t✓t d7 I ., r rf 3 _ . = a t <br /> t.�' . i 1 t .moi e•. i 1 - <br /> 1 <br /> 3- <br /> 4. <br /> 14.Special Hand'rg Instructions andAddtional Infamwficn > i X <br /> rR <br /> 15. GENERATOR'S18FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified•packaged, <br /> markod and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and nation:governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent <br /> Icer*that the waste minimlzatlon statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifl am a small quantity generator)is true. <br /> Genetator's101feror's Pnnted/Typed Name Signature Month Day:. Year <br /> —+116.International Shipments <br /> r D Import to U.S. ❑Export from U.S. Port of er"lexit _ <br /> ? Traasporter signature(for exports only): Date Ieav ng U.S.: <br /> � <br /> 17.TrsnsporierAcknowledcment of Receipt of Materials <br /> Transporter 1 PrfntedrTyped Name Signature Mynth pay Year., <br /> y .. .. r. _ <br /> za Transporter 2 Printed,Typed Name Signature Month Day Year <br /> 18-Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Typo ❑Residue ❑Partial Rejection ❑Full Refection <br /> Manifest Reference Number. <br /> p— 18b.Ahemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> +L+ Facility's Phone: <br /> ;0 18c.Sgnature ol'Allemate Facility for 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 /> LU C3 1. 2. 3. 4. <br /> 20.Designied Facility Cromer or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In rem 1 Ba <br /> 1POntecifTypedName Signahre Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />