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OF <br /> Please print or type:(Form designed for use on sib(12-pitch)typewriter.) Form Approved.OMB No.2656-0039. <br /> UNIFORM HAZARDOUS <br /> 1 to ID m 2.Page 1 of 3.Fmergericy Response Phone 4.Mani Tracking Number <br /> b � �' JJ K <br /> ;,.WASTE MANIFEST ?R -1 6.3 +.�,�:. <br /> 5.Generai Name and Malling Address .d G erator's SItdAddress(Ifdifferent than mailing address) <br /> iy i+a PI�Ft t:T,„>Z.i C+at'� R�ei;o 11ic <br /> • Fre syr OF R".} _ <br /> C 5141,t,.' Z03 <br /> Generator`s Phorad it�:',c':�•� 3 - <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Train of 2 Company Name U.S.EPA ID Number h <br /> LIr tr' .� tZ. ( UV r}-t '_1 .�`, <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 7io E'<;S fi t”co 13La <br /> Fadlilyg Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard pass,ID Number, 10.Conteirre% 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(ffany)) 4 MD. Type Quantity WtAli <br /> .r 3Q.t.f��riil -7= ,:, <br /> O (t��•�t7!.1tx1E.7E6�f�' d3s ,, ''�''�i� <br /> .sGtt.c�r•+�A'�, �Rh' <br /> 3 <br /> 4 <br /> 14.Special Handing Instructions and Additional Infamalion ^ <br /> 15, GENERATOFUSfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fdV and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledplacarded,and are in al respects in proper condition for bwpo't according to applicable irdemationaland rational governmental regulations.It export shipment and I am the Primary . <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowkdgment of Consent, <br /> I cei ity that the waste minimization statement idenfdied in 4t1 CFR 26227(a)(d lam a large quantity gerwator)or b)(If i am a small quarfUty generator)Is true. <br /> GeneratdTalOfterces Pnitte" d Nani Signature Month Year, <br /> (�/Ir\Q� ( -Z()Vl /C #U 1 <br /> 16.IMema6aJai Shipments ❑Import to U.S. ❑Export from li,S, Port of entryfedt <br /> ~ � 1 <br /> z Trarrsportaralgnature(forexportsonly): d Date leaving U.S.: <br /> U 17.TransporlerAcknowledgmentofReceipf rials 1 f ,Iq ^ - <br /> Transporter 1 PrintedfFyped Name a ura'r Mit Day Year <br /> a /�+� 1 Wit._ / / Z zg' <br /> Z <br /> Transporter2 Pnnt0yped�ame ; C nature_ (J Month Day. Year <br /> /p z f(� <br /> 18.Discrepancy Ift <br /> 18a.Discrepancy Indication Space ElQuantity ❑Type ❑Resid6e` 7+ ' "LJ Partial Rejecton El FUN Re)edion <br /> Mar&SLLReference Number. <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> v ' <br /> LL FaditysPhone: <br /> LU 18c.Signature ofAfturiate Facgky(orGenerabr). Month Day Year <br /> y19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,dispesst,and recycling systems) <br /> o t. 2. Or <br /> 20.Designated Facility Owner or Operator:Certification of receipt of harardoua materials covered by the manifest except as <br /> nn yped Nauta r( Signature Month .Dn Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />