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Please print or type.(Fen designed for use on elite(12-pitch)typewriter.) - Form Approved.OMB No.2050-0039 <br /> t <br /> .x I <br /> UNIFORM HA:UZJAIFREDSOTUS1.Generaui Number 2.Pa elof 3.Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE f. <br /> JJ <br /> T :� T - > 'fS•.> �sy.� i, <br /> 5.Generators Name and Mailing Address Generator's She Address(d different than mailing address) <br /> Generators Phone: �') GR7- 1Rrl^ <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Tanspoder 2 Company Name 1 U.S.EPA ID Number <br /> _ <br /> 8.Designated Facility Name and Site Address U.S.EPAID Number <br /> 77, <br /> .i 3 3 ,) Q t 1' 0 t; <br /> Fain sPhome: ') 3+ s� <br /> 9a. go,U.S.DOT Deswip6on(6 during Proper Shipping Name,Hazard Class,ID Number, To <br /> 11.Tubal 12 Unit 13.Waste Codes <br /> HM and Packkng G-P Ransil) Quantity Wt.Nd.IN <br /> 1. •-C] - r,rS -- <br /> T .iCPa FL�'La1L-^^..:tea Y1>^•^.� <br /> 9. `iC37-3C?:+. N.aBAILDOUS *:0.STS, SOLID <br /> 4. <br /> AVX abmx <br /> I <br /> 14.Special Harming NSNMbne arMAddit'unal Information <br /> i ) d233•)0-1567 2 J7`)131or0 Sa o ,.,.+� Or91?3�J7i 73y� 4 O 0131570-11�1� <br /> FRG'TL'nD BY CA:R71EW/S=P= `2 7-3S�D. I"rS 31GYA tLZE •-�--+ _ <br /> MI C?=....'_n ?d'J9T :DA`s�:['Y i�.7_7?� U�� a t'�GT "> .?.li (CJ.:'15+a'..t <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the cantents of this consignment are fully and accurately described above by the proper shipping name,are are classified,packaged, <br /> marked and lhaidecilplaarded,and are in all respects In proper condition for transport according to applicable international and national awemmenbal regulations.If export shipment and I am The Primary <br /> Exporter,I cedify that the contents of 8ds consignment contain to the terms of the abached EPAAcknowledgment of Consent <br /> I certify that the waste mlmimilor,statement dentified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Genemta'steras Prmted/fyped Name Signature t ' Month Day- Year <br /> r i 16.International Shipments ❑Import to U.S. ❑Export from U.S. Partof entrylexil: <br /> H <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> Ina 17 Trenspodeipt rAcknowsedgmerd of Receof Materials' <br /> Transporter 1 PtinittlRype l NameSignature Month Day Year <br /> " av,eY 'AC c') Ct raj - �—J—� — f� I > <br /> Z Transporter 2 Prumted7fyped Name Slgnahxe� ', ' Monts Day Yeer <br /> i18.Dtsaeparncy L/ " <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Refection ❑Full Rejection <br /> Manifest Reference Number. <br /> F 18b.ABemate Facility(or Ganeralor) U.S.EPA ID Number <br /> J <br /> U <br /> Fadlity's Phone: <br /> w Ise Signature ofAllemale Faality(or Generator) Month Day Year <br /> d <br /> Z <br /> 7, <br /> N 19.Hazardous Waste Report Management Method Codes g.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> o ,. (� z. 2,2- <br /> 20. <br /> 20.Designated Family Owner or Operator.Codification of receipt of hazardous materials covered by the manifest except as acted In Item 18a <br /> PrintedlTyped Noma( Iti^y f; , —7 Signature I r' ^ ! ,�� MoM� Day. Year.. <br /> '� '�.` t / . i <br /> EPA Form 8700-71(Rev.3-05) Previous editions are obsolete. D'c51GNAT S3 FACILITY TO GENERATOR <br />