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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) , �^ -+ r% <br /> `3 ' Form Approved.OMB No 2050 D039 <br /> UNIFORM HAZARDOUS AZARDOUS 1.Generator 13D�Number 2,page 1 of 3.Erm pin y Response Phone 4.ManifestTrdcking Number <br /> WASTE MANIFEST _r V' (�J :lr^ 3EE �}' -r c�-,� es Y' spa f <br /> � L � ;P,, <br /> 5.Generators Name and Ma ling Address r l{�� t (� —Ting ad� <br /> ����•� a*:�a°�.. L�e �'t{ �,l�1at's sde aedress d�aient than ) <br /> Generators Phone. <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Numberi h <br /> 7.Transporter 2 Company Name U.S.EPA ID Number- <br /> Designated <br /> umber Designated Facility Name-and Site Address U.S.EPA ID Number <br /> FaaTrtysPhone''E-•c'"7's- =r'rr _ . <br /> ga, 9b.U.S,DOT Description(Indudmg Proper Shipping Name,Hazard Class,ID l4rattba 10.Cotrlahtws 11.7oha1 12 Unit <br /> HM -and Padding Group Cif any)) <br /> No - 'type 'Quantity. WtNcL 13.N/d6e Codas ;"• . ' <br /> F11. .__ L ��_- —�---•�r� <br /> W 2 �r"-Fs:,:-tz?Jf?n•3rch:tS1F:�:7 [ �7i! <br /> V. <br /> ='c�'t:�•��..�� c.C.ii - - f'��1 may-+, <br /> 14.Spedel Handing InslructionsandAddtional Udonnation <br /> al'rr'^i7.'7QJ <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION:1 hereby declare that the conleris of this const nment are fully and acaualely described above by Ore proper shipping name;and are classified,packaged, <br /> marked and labeted(placarded,and are in all respects in proper condition for transport accordurg to app6able mtematiotml and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents ofthis consignment conform to the terms of the attached EPAAduxWedgmentaf Consent <br /> eer9fytlfetthe waste minim¢atien statement identified n 40 CFR 26227(a)(d I am a large quantity generator)or(6)(dl am a small quantity generator)is true. <br /> Gehenit�sfOtfemes Printed/Typed Name., = SignadAe;;f Month Day Year <br /> _J 16:International Shipments ; 1 <br /> t- ❑Import to U.S. ❑Export from U.S. Port of entry/exit' <br /> Z Transporter signature(for exports only): Date Isaft U.S_ <br /> LU <br /> 17.TransperterAdmoWedgment of Receipt of Materials <br /> Transporter 1 PrintedCryped Names Slgrtalure" E 1 Month Day. Year <br /> tat <br /> za.Transport�2 Prhledlfyped Name L . Sigrralure' j' -'-H'- Moitlh' Day Year, <br /> %Discrepancy <br /> 18a.Dimrepancy Indication Space ❑ Quantity, <br /> El Type El Residue ❑Partial Rejection. ❑Full Rejecfion.: <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> 4 Faults Phone: <br /> W 1ft Signature of Alternate Facility(or Generator) Month Day. Yew <br /> a <br /> Z <br /> 1&Hazardous waste Report Management Method Codes.p.e,codes for hazardous waste treatment disposal,and recycling systems) <br /> G 1. 12- <br /> 20. <br /> Designated Facility Owner or Operator.Certification of recelptof hazardous materials covered by the manifest exceptae noted In Item 18a <br /> PrutedrrypedName `. f. Signature I'Month Day Year. <br /> EPAFdrm 8700-22(Rev.3-05) Previous editions are obsolete. QESIGNATED FACILITYTO GENERATOR <br /> i. <br />