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Please print or typo.(Form destped for use on elite(12-pitch)typew her.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Pae I of 3.Emergency Response Phone 4.Marrf�t Trio ng umber <br /> WASTE MANIFEST : .� r ., 4, 015482451 JJ K <br /> 5.Generators Name andIk alga Addnsa� vi A Generator's Site Address(d diRerent then,mailing address) <br /> 7: 1t," <br /> I. (•..Orf <br /> Generator's Phone: { '5 <br /> 8.Tragsporter 1 Company Name U.S.EPA ID Number <br /> / V <br /> 0`/>1.•tr' }` `. 'r::ew.''Itr n ��d�r✓.J, '� G I'! <br /> K <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.gesignated Facility Name and Site Address U.S.EPA ID Number <br /> Facgltys Phone: <br /> ga• 9b.U.S.OUT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contanam 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity W Wat p <br /> a, 1'/,lN�e:rl. st.l FT J f•{ .,�r'i_. .:Jr f•. t' ii:,Y, *✓! f'j J: t � ;.. �:.=C:r J.7 1 <br /> • � I <br /> Z 2. <br /> LLI <br /> I <br /> 3. <br /> 4 <br /> j <br /> -4- <br /> 14. <br /> 4- <br /> 14.SpedelHanrdtl`/ sand dill allnformation r3/gr�r'u;', .r:�> <br /> 1 � f'K�L7 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents oT this-consignment are tufty and accurately dtscdbed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledrpacarded,and are In all respects in proper condition for tnanspottaccording to applicable InWmatlo el and nabohaf govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of ttta stied ed EPA Acknowledgment oPConsent. <br /> I certify that'the waste minimizabom statement identified In 40 CFR 26Z27(a)(#I am a large gtantily generstgr)er(b)(91 am!a small quantitygenelator)is true. <br /> Generatoes/Offeror's Printedn'yped Name Signe)ure Month Day Year <br /> =j 15.International Shipments <br /> w ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> ? Transporter signature(fou exports only): Date leaving U.S.: <br /> ELI 17.Transporter AdmWedgment ofReceipt of Materials - <br /> Transporter 1 Printed/Typed Name Sign" ,-' Month Day Year <br /> ,I <br /> • <br /> • .� y <br /> Transporter 2 PrintedfTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fug Rejecicn <br /> Manifest Reference Number: <br /> 'I 8b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Aftemate Fac lty(or Generator) Mon Day Year <br /> Q - <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systema) <br /> 0 1. 2. 3. 4• <br /> 20.Designated Facility Owner or Operator.Cenci cgcn of receipt of hazardous materials covered by the mar*st except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />