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please print or type.(Form deslgned;for use nn elite(12--pitch)typewriter.)- Form Approved.OMB Nri:2050-0039 <br /> s UNIFORIN HAZAR60US 1.Generator ID'Nu/mbet' 2 Page 1 3 Emergency Response,Done one 4 Manifest Tracking Number Cr <br /> i WASTE MANfFEST 4:1 ..' ( 3�I ... . . ��'"./ � 4 > 00,03 58:85 5 FLC- <br /> 6 Generators Name and Mailing Address „ p1 ,. f, Ge%�r Site Address if diff rehan mailina�ddress){ <br /> A nerator s Phone (,� .w �,'�p x, w - " <br /> -6 Transporter 1 Company Name -Fr a r U S.EPA ID Number <br /> + - <br /> x 7 Trarrsporter 2 Gompany Name -- U.S'EPA IDNumber,'•� ,-' -� -. , „ „ �,.. ..,��. <br /> <- .8 Desrgnaietl Fapi!4 Name and Site ss- U.S.EPA ID'Number <br /> V50 <br /> p Gti YGr ,f;Er f'- Z l/ <br /> Facrldyshone. Zc3 „..,..Gq <br /> ga 9b.U.S.DOT Description(inclu'ding Proper Shipping Name,Hazard Glass,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)} No. Type Quantity Wt.Nol. 13.Waste Codes <br /> W 2:' c�Rlasfy*y7 ( Car' yf 4. �• �%� " f <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'5fOFFEROR'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-ail respects in proper condition for transport according to applicable intemationai and national I 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(x)(61 am a large quantity generator)yr(b)'(f I am a small quantity generator)is true. <br /> Generators/Offerors PrintedlTyped Name bigna ur ( r ---90—rlh Day Year. <br /> 16.International Shipme is ❑ / <br /> Import to U.S. Export from U. Part of enirylexiL <br /> Z Transporter signature forexports on€ : Date leaving U.S.: !` <br /> U 17.TransporterAcknowledgment of Receipt'cf Materials <br /> Franspo -PrintiypedN a Signal Month Day F,,-ear <br /> Q Trani 2 Printed/Typed Name Sig ature Month Day Year <br /> M <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑PartiaE Rejection, ❑Full'Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Numliet <br /> U , <br /> a <br /> IL Facility's Phone: <br /> UJ 18c.Signature of Allernate Facility for Generator) Month Day Year <br /> a , <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 /> r�5 <br /> 20.Designated Facility Owner or 0 eralor:Certification of receipt of hazardous materials covered by the manifest except as n ted iniltem 18a.f <br /> PrintedfT /Name r Signature r r i" Month Day Year <br /> Lld 141 (A J <br /> EPA Form 8700-22(Rev.3-05).Previous editions are obsolete. .+ DESIGNATED FACILITY TO GENERATOR <br />