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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 11 1.Generator ID Number 2 Page 1 of 1 3.Fmergency Response Phone 4.ManlifestTtaacking Number <br /> WASTE MANIFEST �',C`\, V .1 �''�)(�: G E'' r ✓� .^iC: .: L 1 ti JJ K <br /> CJ <br /> 5.Generator's Name and MailingAddress` y J { Generator's Site Address(if dHferent than mailing address) <br /> Generator's Phone: ! <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.FPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Ci <br /> 5�1�:��,�Tip4 tC•^. :.i+ivirv;r."•;ra:,.,r <br /> it}�.'^;off��i�.I_�,L?', _•i L�t:t.;��. <br /> Facility's Phone:; <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Con ta ners 11.Total 12 Unit 11 Waft Codes <br /> HM and Packing Croup(rf any)) No. Type Quantity WtNol. <br /> O <br /> Q <br /> LU <br /> LU <br /> 2CD <br /> rl Jt•T t!(Jtq•-•'ti!1!`i '\r./'Y,�U:j is}i:�Td� ��t1LI t°.�fLi v4lL'Ir'] Y,�^Ti•CtS'I_i.+ �.. -—_ <br /> 3. <br /> 1 J <br /> 4. <br /> i� <br /> 14.Special Handling Instructions and Additional Information <br /> ':��14'r.J i°S'_ - �i� }ri��7�. fie- �.. ori itlS :^:i'� '� h _•�7.__: -.�- ^e.- <br /> R_ci �T- <br /> ';,�i.Lf�hitJ�� Lti_d It='s �L,'—�%;•T'cs_.. __. !�hi`f�iTrt.�r, sLTR,�3�T: ii*drt• r..;{C <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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national govemmental regulations.If export shipmentand Tam the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached FPAAcknawledgment of Consent <br /> I certify that the waste minimizabon statement identified in 4D CFR 26227(a)(d I am a large quantity generator)or(b)(dl am a small quantity generator)is true. <br /> GeneratorVOfferor'sPrinted(Typed Name Signature` Month Day Year <br /> _r^' cif%f.-f•�� - � � <br /> J 16.Intemational•Shipments <br /> E] ' o" <br /> If to U.S. ❑E pon from U.S. Port•of entrylexrt <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> C nowReceipt 17.TransporterAckledgment of Ript of Materials <br /> � F <br /> Transporter 1 Printed/Typed Name } Signature Month Day Year <br /> CL <br /> z I Transporter 2 Printedrryped Name _ Signature i Month Day Year <br /> C y <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceQuantity T)Pe Residue Partial ReIetion Full Rejecon <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ua FaLiTtys Phone: <br /> F18c.Signature ofAltemate Facility(or Generator) 7Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(7_e,codes for hazardous waste treatment,disposal,and reading systems) <br /> 0 1. 2 i 3. 4. <br /> 20.Designated Faality Owner or Opar2tnr Certification of receipt of ham sous materials covered by the manifest except as noted in Item 18a <br /> Printed yped Name I 1 �t Signature ) Day Y <br /> `P; I11� <br /> EPA Form 870022(Rev.3-05) Previous editions are obsolete. 1 DESIGNATED FACILITY TO GENERATOR <br />