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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manliest Tracking Numher <br /> WASTE MANIFEST C A (7 J Fi ; g !) t•. _ r; I 1 012296133 JJK <br /> 5.Generator's Name and MailingWic, ss Generators Site Address(if dimerent than mailing address) <br /> t.lrgf{od arrjla kA Inc. Urtikad Grocers,. ku <br /> 5:0[}Sfrcef `;A C IW Piccral Roato <br /> Generators Phone: ' (L 1.0 d 11j y ti �� <br /> 6.Transporter Company Name U.S.EPA ID Numher <br /> K-VA(,t-nwrolarnenha1 'icwi ,xns (7 A ft C1 q O 1 t3 '3 O fl 7 <br /> 7.Transporter Company Name U.S.EPAID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Vr-fft F1 TGk11111Pf�fiWUIkN19 <br /> 1)`04 W First fit <br /> A7115a CA 917W <br /> Facllitys Phone: - CT.`E (; A Lt 0 (J ti <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(rf any)) I No. Type Quantity Wt.NoL 13.Waste Codes <br /> F1.Uhi1791, I'(y�10�.1liiXtld ti001"tsi � CS 1 <br /> W <br /> OF 1 / 15 G <br /> C7 'J J� ?4'� <br /> c3 rIf1 (/ a <br /> 3: <br /> it <br /> 4. <br /> 1 <br /> 14.Special Handling Instructions and Additional Information <br /> iCc.,•ir •r{.i.i `a' T 1a,t r: p(.F. I ,. .t i I.. ti <br /> 15. GENERATOR'SIOFFEROR'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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneretorsMerors PdntedRyped Name Signature Montp..-. Day Year <br /> r. <br /> 16.International Shipman 3 <br /> is <br /> Z <br /> 11 Import to U.S. ❑Export from U.S. Part of entry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17 TmnspoduAcknowledgmentof Receiptof Materials <br /> OTm poder'1r Pnntedffyped Name F? Signature ? Mon y Year <br /> -o-c" � �/! <br /> Transporter 2 PrintedRyped Name Signature C <br /> Month Day Year <br /> H <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑T e <br /> YP ❑Residue ❑PaNal Rejection ❑Full Rejection <br /> 18b.A1temate Facility(orGenerator) Manifest Reference Number. <br /> J <br /> U.S.EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> w 18c.SignaNre ofAltemate Fadliry r Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. <br /> 4. <br /> 20.Designated Facility Owner or Operator ificd n of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prxited; yped Name Signature Month Day Year <br /> EPA Form 00-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />