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• .. ..-_......_...✓ .:1...�_.-..}may....- -;-. ., ...- .......-•- •------• <br /> 1 <br /> Please tinter tppy:(fiorm designed for use on'elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Gerara;or IC Number 2.Page 1 of 3.Emergency Response Phone 4.Nanifest Trac(ring Number <br /> ' �r� p� "A �� JJ K <br /> WASTE MANIFEST r".: .:�. :� !:r i) :. $ �-� [, _ .. � {f;:fjt u:. •-��u� ��d. �F I3,;���.•.�' <br /> '5.Generator's Name and Mailing Address Generatoes Sire Address(if dti`erent than mailing address) <br /> „term.V17 <br /> YZ 'i fr _ `r `73Ltil , <br /> Generatoes'Phone: <br /> 6:Transporter 1 Company Name. U.S.EPA ID.Numtx r <br /> .t 7 1 a :i <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> B.Desigrated Facility Name and Site Address U.S.EPA ID Number <br /> Ta" 'E <br /> `,.i.ti.ntt 11:i��CS1��,r,U'�`J SJ.J•.' :.1:J•� , <br /> a3 7 5 S <br /> P, IMI"`^ 7•• - - <br /> wiliCiL�' <br /> CA SI)C;5Y w <br /> x' 0- 9 7 0 1 0 9 3 <br /> Facilit's Phone: i ti 2� 50 0 <br /> 98. 9b•U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if an µo• Type Quantity Wt.No1.. <br /> 1Tk!yiik..Ar•��8 i='Y•.i��.�l'i.^r;1C tif84'f''F` X,^, yI•S rr^:','T« C(',Y.Tr1C1 .. ;moi y <br /> 2. , t <br /> C9 4 �s <br /> rrrn .9 <br /> 3• r <br /> NV RONFME TA; <br /> 4. �... KIT <br /> 1 <br /> 14.Special Handling Instructions and Additonal Information '•- L f �; i� <br /> r= REC 1-800-424-9300 IQAEKt30 9BI <br /> . 171. ZRcFIL .0 9B . <br /> ),-r, S7 641 '01 LY zD- 0! All 0 1526', *, xpGrRIFZE PER.,SOIvpL bAj-T-D�ti -r LTP <br /> AMYT I <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of the con..�gnrent are fu ty and accurately described above by the proper snlpNng name,and are cIfled,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport accord',ng to applicable international and rational governmental egulations.If export shipment and I am the Pdmai <br /> Exporter,I'certify that the contents of this consignment conform to the terms of the attached EPAAcxnowledg rent of Consent. <br /> I certify that the waste minimbmtlog statement identif ed in 40 CFR 28227(a)(if I am a:arge.quan4' tor)or(o)(if I am a snag quantity gereratcr)is true. <br /> siefte ajor•sfOfferors Pdnted/Tppd•Afamep rate Month Day Yea* <br /> 16.lntamaboaaMprlhtqt5 ( ti ,11 <br /> Import to U.S. ❑Eom from J.S. of entryiexit <br /> = Transporter signature(for exports only): Dare leaving U.S.: <br /> LO: 17.Transporter AdmowledgmentofReceipt ofMaterials <br /> Transpo t Pdnted7Ty�.. Signatare Month Day Year <br /> ITQ Transporter PrintedlIyped Name 'gnature Month Day Year I' <br /> r O I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Tae <br /> TY, ❑Residue L1 Partial Rejecticn ❑Full Rejection <br /> Manifest Reference Number. ' <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number f <br /> J l <br /> V <br /> LL Facility's Phone: <br /> 16c. <br /> Signature of Altemate Facility(or Generator) Month Day Year <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste 7eatment,disposal;avid recycling syet@ms) <br /> p J3. <br /> A r <br /> 20.Designated Facility Owner Operator.Certification of receipt of hazarocus materials covered by the manifest except as noted in Item 18a 9 <br /> Pd Slgnature,� Pi <br /> B Y r <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GEIIERATOR STATE(IF REQUIRED) <br />