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Please pnnt or type. (Form design for use on elite (12-pib <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />WASTE MANIFEST 17 .1,117100 <br />5. Generates Name and Address <br />C' it 4 i. F'J luta Is 'V',% 11111, f. t ctrw r F„�• <br />35.0-5 g EL uox:►eir. E4t <br />%Lookt.crn, <br />F"4010-47 -47 Hnv4,14, :Etat_ . <br />.t.) BOW .576, Ei1yx 93, t AIa JLR•- I)rrxC I. Y� <br />fticattlt NV 491)401 <br />F s Plane: tillo <br />9a, 9b US, DOT Descrptan (including Proper Shipping Name. Hazard Class, ID Number, <br />HM and PackNlg Group (it array)) <br />ceO <br />Uj <br />w <br />X 1 12, <br />U.1 <br />O <br />iI <br />s <br />Forrn Approved. OMB No. 2050-0039 <br />3 Emergency Response Phone 4. Manifest Tracking Number <br />-- �. 00-:)Q.-)098 FLE <br />U <br />J? <br />10. Containers 11. Taal 12. UM <br />No Type Quantity WL/Vol- 111 WNW Codes <br />14. Special Handling Instructions and Aciditorai Information <br />(! 1)itl1231i1ti 1•!ti'+' I_A!i <br />P v rs 't• L.arn c t'7(�, 77L? }y <br />15. GENERATOR'StOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper srspprng name and are classified pamagea <br />marked and labeled/placarded, and are in as respects in proper conditon for transport according to applicable international and national governmcrtai reguiall if export shipment and i am ane pinery <br />Exporter, I cenry sial the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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 1 am a small quantity generator) ri inx <br />Generalkirs/OfFerices.Pnnted7yped Nar.ne Signature <br />L <br />ay ear <br />^ <br />-.r <br />i— <br />16. International Shipments <br />❑ Import :o U. S ❑ from <br />EVW U.S. Port of entry/exit <br />- <br />1 ransporter swatum for exports on Date ,ea U.S.: <br />Li <br />17. Transporter Acluo ledgment of Rempt of Materials <br />W <br />ansporter Pim yped Name <br />Year <br />O <br />crLna <br />�' <br />'+ '4 : 1 <br />j <br />+�.• "= �, 1 { � .' tt. Lt .a4' <br />z <br />Q <br />Transooriar2 PrInted?Typed Name "Wremorith <br />par <br />d' <br />16. Discrepancy <br />6a. Discrepancy Indication Space ❑ Ouantty n Tape ❑ Res due ❑ Pareat Refection <br />r�t <br />❑ Ful Refecoon <br />Manifest Reference Number <br />J <br />18b A!t°mate Facility (or Generator) U.S. EPA 10 Number <br />U <br />Q <br />w <br />Facility's Phone: <br />LU <br />18c. Signature of Aitemate Facility (o(Generator) <br />Month Day, y -,v <br />r— <br />Q <br />2 <br />N <br />19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment. disposal. and recycling systems) <br />w <br />0 <br />' <br />2.3 <br />4. <br />?J Designated Facility Owner or Operator: Cartifimbon of receipt of hazardous materials coveW by the manifest except as rated in Item 18a <br />PnrtW.ypedName Signature <br />Month Day Yeat <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />