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Please print or type..(Form designed for use of elite(12-pitch)typewriter.) ) Form Approved.OMB No.20WOD39' <br /> UNIFORM HAZARDOUS- 1.Generator ID Number 2.Page 1 of 3.Emergency'Response Phone 4.Men eat c ng umber. <br /> WASTE MANIFEST ' Ib;? SS ?+ ( .. 00 .ta.� �1 FLE <br /> 5.Generators ame and ailing Address Generator's Site Address Cif different than mailing address).'ello . <br /> d-W MT <br /> ;1i'��G fK�RWA <br /> I VF <br /> Generators Phon88ii -2'1.. <br /> CE <br /> T.Transporter Company Name ' S.EPA ID Number <br /> Mao <br /> 7.Transporter 2 Company Name. "'. U.tf+ S.EPA ID Number <br /> B Designated Facility Name and She Address S.EPA ID Number <br /> l;r�wraz3o,�ca �t �Iftserrt MENTAL HEi�1LT1-Y' . <br /> RE <br /> b ,',3 E0, <br /> r ' DE�"ARTIIIIENT: <br /> Facility's Phone:N S�•°,'�M$2.20 <br /> ga; fib.U.S.DOT Description(including P(operShtpping Name,Hazard Class,ID W.mbar 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(If any)) No, . Type Quantity Wtivol. <br /> fw .(�a��'I'dA :Yr"dKd+�C�rSTitt� ulcJ$et, $K�bl � C l:/ <br /> tZryy . 2 <br /> C' <br /> 3. <br /> 4. . <br /> 14.Special Handling instructions and Additional Information <br /> ,,t 'st:�14eS17Y'r�h" � � s '.'tUt788it4$iit1:1�1f�' , <br /> 18..'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 labels liplacarded,and are in all respects in proper condlon for transport according to applicable international and national governmental iegllations:If export shipment and I am the Primary , <br /> Exporter,I cerllfy that the contents of this consignment conform to the terms of the attached EPAAcknowdedgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(d I am a small quanfity generator)Is true. <br /> Gener!atofs;Offerors PrintedlTyped.Name Signature on y Year <br /> � is.Infemational Shipments <br /> F- Import to U•S. ❑Export from U.S, Port of entry/exit <br /> — <br /> Transporter sinature forexports'onl. : bate leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pdnted/Typed Name Signature onth. ay ear <br /> Ir <br /> Transporter 2 Printe ed Name Signature ,r _ Month Day ear <br /> 18.Discrepancy <br /> 18s.Oiscrepancy fndication Space ❑ Quanfity ❑Type ❑Residue ) ❑Full Rejection <br /> ❑Partial Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Fatality(or Generator) U.S.EPAiD Number <br /> a Facli s Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> S2 19.Hazardous Waste Report Management Method Codes Q,e.,.codes f0azardcus waste treatment,disposal;and recycling systems) <br /> 0 1 Rf 2. 3 4' <br /> /,/-20,Designated Facility Owner or Operator.CeTgflcetion of receipt s metenele overed by the manifest exq*as noted In Itarill.4 <br /> nted(ryped.Namer� = r I j ! Signature r �" Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Prev](mis editions are obsolete: DESIGNATED ACILITYT0 GENET ATOR <br /> J. <br /> i <br />