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Please. 'nf1or' Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No-2050-0039 <br /> NIFORM HAZARDOUS 1�nerator ID Number :2:•P69e 1 of '3.Emergency Response Phone' 4 ManifestTracMng Number <br /> WASTE MANIFEST <br /> 5, erat s Name and l ng Addy ss Generators Site Address(d d(flerent iter maaing address) <br /> r <br /> Generawrs Phone: <br /> 6.T p 1 Co ny Name U.�•>zPA ID Number <br /> •7,Trarisporier2 Company Name U.S.EPA ID Number <br /> 8. esi a FaciBty Name e f fes,,� ,3 �r/ / U.S.EPA ID Number <br /> %0 <br /> W - <br /> 9a. 9b:U.S.DOT Deserlption(nduding.Proper Shipping Name,Hazerd.CAss,ID Number, 10.Containers11.Total 12;Unit 13.Waste Codes <br /> HM and Pacidng Group(f a No, Type Quantity w6vol. . <br /> Vh <br /> _ <br /> 3. <br /> 4: <br /> 14.Spe(al Handlin .inshuctiors and Additional Information <br /> -- <br /> -ed- <br /> -and— -- <br /> ts GENERATOR S10FFEROR'S CERrtFICATION YherebyVeciare thatthe�6ntents'of tltiSa�nsigrInWrarefUV IxLratel Scribe"b0Va by:ttle-properSlSgtp tto t8 c <br /> marked and labeled placarded;and are.in all respects m proper condition for tanspori:according,te applimble international and national governmental:regulations.f exporS shipment and l am the Primary <br /> Exporter,I certff r that the contents of this consignment conform to the terms of the.attached EPAAcknowledgrnent of Consent. <br /> Lpirtily-that the waste minimization statement identified In 40 CFR 26227(a)(If I am a large quantity generator)or(b)Qf I am a•small quantity generator)is true. <br /> eretorsg3ffetor' ?rirrtedfTyped Name Mon Day Year <br /> :f 16.International Shipments ❑Export from U.S. Port of entry/exit <br /> ❑Import to U.S, <br /> Z <br /> Transporter signature(for exports only): Date leavinuU.S.: <br /> W .17,Transporter Ae owledgmem of Receipt of Materials <br /> Monte Day' Year <br /> Signature <br /> revf " <br /> �. Tnmpo � tedrryped Name , <br /> .0 <br /> a 1 Month Day Year <br /> Z'Tran anter 2 PrintedlTyped Name Signature <br /> a <br /> 18.Discrepancy <br /> 18a.Discrepancy Indita6ort Space O quantity ❑Type ❑Residue ❑Partial Rejection D Full Rejection <br /> Manifest Reference Number. <br /> U.S. ID Numbe <br /> Alternate Facility or rabr}. Sy� <br /> AC2 �� <br /> tL Facihry S Phone. Month Day Year <br /> Wi 18c.Sgnaiure ofAitemate F8ci611y.(ov Generator). <br /> F <br /> y19:Hazardous Waste Report Management Method Codes(.e.,codes for•hazardotrs waste:trealment d sposal,:and recycling systems)` <br /> LILL113. <br /> 4 <br /> 20.Designated Fedlity Owner or Operator.CerV cation of receipt of hazardous materials covered by the merriest e as in Item 18a... Month : _Day <br /> Y <br /> Prim Name r — S�1 <br /> Form 00-22(key.34Q5�) previous editions are obsolete. . DESIGNATED FACILITY TO GENERATOR <br /> 4Z 'd BIBLOOBS02 JUOpUi>I .4dac, e02 :0T SO TZ 1400 <br />