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Please print or type.�Fomi designed for use on elite(12-pitch)typelvdter.) Form Approved.OMB No.20540039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mandl Tracking Number <br /> WAStE MANIFEST - ' ! ., n , - ' ' F' t'f':t,i.:{�il" ,,'. 014891371 JJK <br /> 5.Generators Narne and Melling Address iDerreretols Site reser ItryiSerant than mailing address) <br /> - <br /> trl Stc•nerda< '�s,PDa] 4ttn -IF i•j F-RC fl,z;4s <br /> I'14'e53nR'n (A lr:I S:nR �fOCrk LOr '�-.P. 'gn�•!I: <br /> Cenerszrys Phone' 17 U' - %• 5 0! U <br /> 6.Transporter 1 Company Name U.S.EP ID Number <br /> Ernlronrnenial Lawstic5. me <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,peeignaad shy Name and She Address U.S.EPAIDNumbar <br /> NaZ!t'2i.r?C <br /> 6-]p Stadwrn Dr <br /> Fal Phone: c!1` n:'d_RQ�! n,1 it n :� >; f '2 3,C' 1 <br /> ga. 9b.U.S.DOT Descrption(including Proper Shipping Name,Hazard Class,ID Number, 10.00 kis 11.Total 12.Unit 13.Waste Cues <br /> HM and Pacing OMP(t a")) No. Type Ousnhty VVUVOL <br /> i3TTOO:•a ,wJ1is n n s Ipaso0!19i, II <br /> w <br /> A� <br /> Z I <br /> 3. <br /> 4. <br /> 14.8padat Handling InsinuctionsandAddifional Information ;+l'- 1. <br /> 15i GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desolated above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and ere in all respects in proper condition for transport according to applicable intemjtionalnntl national govemmenatregulatins.I export shipment and I am the Primary <br /> Exporter,I certify that the contents of his consignment conform to the arms of the attached EPAAdmov4edgmept of Consent. <br /> I cera that the waste mmimlratian statement identified in 40 CFR 25217(a)(a I am a large quantity gene 'or(b)(MI am a small quarN generator)is We. <br /> Generatols ola Pill ped Name - J 9ce I �, Month Day Year <br /> X I i�Y Il 1 \.I L?�� ( ick � .✓�— ` fk.^� L` IL <br /> 16.Intima Shipments <br /> r— ❑Import to U.S. ❑Export from U.S. Port of enbyledt <br /> Transporter signature(for exporte only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment ofRece'otofMinerals <br /> Tof <br /> ��ner 1 Pdnledffyped Name Signal _ I Montt t Y Year <br /> N LJIf: ( l FIiCI (c-t CE nor a ( �f <br /> M T•anspener2 Frintilawlypearsame Signature Month Day Year <br /> Q <br /> IY <br /> I <br /> 18.Discrepancy <br /> Aha.Discrepancy udicaton Space ❑ Ouantily ❑Type El Type ❑Partial Rejedii n ❑Fu1I Relectian <br /> Manifest Reference Number. <br /> 19b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Ox uE <br /> Facility's Phone: <br /> 18c.Signabuirs of Ahernate Facill aGenerator) Month Day Year <br /> Y <br /> h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treati enalr disposer!,and recycling systems) <br /> O 1 2. 3. 4. <br /> 20.Designated Facility Owner a Operator CerGfiwbon of receipt of hazardous materials covered by the maintain except a, a Item Ise <br /> Print amen (� Signature, //''�� an ay ear <br /> EPA Form 8700-22(Rev.3-05) Previous editions ere obsolete. ✓ DESIGNATED FACILITI)1'O GENERAT <br />