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.. ---- - - -- <br /> Please:rintar. 7jform designed for use on-elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Genera or lD'Number 2 Page 1 of 3.Emergency Response Phone <br /> _ ' . Manifest TraeginNumbe <br /> r <br /> WASTE MANIFEST ryr J fi " u^, ..��L� 8`Z <br /> , "'4 -1- 4 B .3 6 <br /> JJ K- <br /> '5. <br /> Generators Name and Mai Address Generators Sive Address(it difere-it than mailing address) <br /> . U. L; <br /> 952E SiU('KICl:"7 <br /> -3 217 <br /> Generator's Phone: "' <br /> 6:Tra„„nsporter1 Company Name. ri t 7 c U.S.EPAID.Number 1 7 <br /> I"m7 AT'.iiJ 1:,x �,�:i'\3.�.1\t�)tili'Sl;.t'i rL'I''>�J i%J.:.d\S 1..L5S .. �+t 21 ;.! (,! r .G 1 / <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Faclli Name and Site Address U,S,EPA ID Number <br /> Z '..ra U-A”'. '.l'l •l��•lS.lb�.i '�/lJ 11:i.1 :.I:Jv _ <br /> .. .,�,. i �_Z tit {�— (: R _'• i 7 �3 G y <br /> Facilil's Phone i.�3•=, N <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(it an 13.Waste Codes <br /> No. Type Quantity WLNoi.. <br /> �. 1}kt-;r's-,.ur•to& i-?'<�i�TrYc^:;rC iT`uCT'F` �^„J m.i <br /> TAILLI <br /> Cfif.7'F1C1 I <br /> 2. / <br /> Llj <br /> • 3 l <br /> 4. <br /> ( <br /> I <br /> 14.Special Handling InSINCttOns and Additional Informationti <br /> 1^•900-424-9300 I4AEKGO RZtl f%> :. PROF-1.1-g. P G. G <br /> /1 r rv. .L..ani:r P TL c R 'T. �• <br /> +,�G +_. '�r:1.I;T Ft•` � �u€f �'i r r ' � , L'� '(',� i ��Y^r •may. r <br /> t"S. !.�L�rLO� ccY� �..Yt��Fs.2E �T'.i�VQ[}1''c,.. .0 ti�rT i!• �''' ..."ia'x!�JZg��T i1 " <br /> 15. GENERATOWS10FFEROR'S CERTIFICATION:I hereby declare that..the contents of this consignment are fu ly and accurately described above by the proper shlpplrig name,and are cla Ified;packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport accord'mg2o applicable international and national governmental regulations.If export shipment and I am the Pdmaiy!•. <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent j <br /> I certify that the waste minimizatlor statement identified in 40 CFR 262.27(a)(if I am a:arga.quentity tor)or(o)(if I am a small quantity generator)is true. <br /> ,Qer.%mtoPs1Offerors Pdnted/TyP_ed.N-3me Si net re y Month Day Year <br /> -j 16.IntematioaaOSt IOan ( 5 t 1 <br /> ❑Import to U.S, ❑Export fro"r J.S. —✓ Port o1 entryiexit <br /> Z Transporter signature(for exports only); Da•.e leaving U.S.: <br /> W 17.TransporterAdrnowledgment of Receipt of Materials <br /> Transporter'Printecffyped Na".. i —• SzgnaUre / Month Day Year <br /> a ri':�' /�•�fi /"',�`✓��R - i ...x'f'" G ..F-G•= ten.+ �Cf• r� <br /> QTransporter 2 Printed yped Name Month flay Year I: <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Tyae ❑Residue ❑Partial Rejection ❑Fuil Rejeotlon <br /> J ,4 <br /> *• Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> C <br /> U <br /> w Faclitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a - <br /> 19.Hazardous W1asta(Report Management Method Codes(Le.,codes for hazardous rras'e teaFmerd,disposal,'ano rebydffng systems) <br /> 2. <br /> LU <br /> 20.Designated Facility Owner ortpperator Certification of receipt of hazareous materials covered by the manifest except as noted in Item 18a <br /> Pri dllype l <br /> Signature FNWn D Yi✓ � /t 1x ja "� f •K�'__�, �f r 4LJ <br /> EPA Form 8700-22(Rev.3-.05) Previous editions are obsolete. ✓ �DESIGNATED FACILITY TO GEOEEtATOR STATE(IF REQUIRED) <br />