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Please print or fype (Farm designed for use on elite (12 -pitch) typewriter <br />UNIFORM HAZARDOUS 1 Gene�IDberWASTE MANIFEST W#0,t.j.7 t r <br />5. Gercerator's Name and Ma;img Address <br />Cs 1 iFnttrs.i n f srs!. { , are. v 7r•r. <br />rku�ct+►r., r� Vti7tld <br />Generators Phone: :•ito ;{�� yggq <br />ransportar 1 %Ximpiiiffty Name <br />AcltirL-twoac.ni L'rsstxpt>�t <br />(-h-11111111--i Tins clot ltKaiaycsarsast <br />3525.t ina Sl. Y t arse Dord <br />Qbt i .I.C:rirlil rot, C':1 !1i2iq <br />Fa s Phone: 56II - -17 n- V 7 j 1 <br />9a. 9b. U.S. DOT Description (inducting Proper Shipping Name. hazard Gass, ID Number, <br />HM and Packing Group (If any)) <br />Pi,Ha �tCfiR Uasaas�lora: bras 1 e , { <br />O <br />f— <br />w <br />z 2 <br />LU <br />0 <br />0 <br />Form Approved OMB No. 205M030 <br />1 of 3 Emergency Response "we4. Manifaat Tracking Number <br />; .� , -7 F L E <br />re„e_...,,... .._ .. -', v <br />10. Containers i 1 Total 12 Unit -- <br />wt -"M <br />13 Waste Codes <br />No. Type Ouantny <br />1, <br />krci'�ee:.•t fit -'amber —, VVaI27t# - I's .i. <br />15. GENERATOR'SIOFFEROR'S CER11FICATION: i hereby declare that the contents of this consignment are fully and accurately cesmbed above by the proper stwppN rano, and are uassdced. P30,Wed <br />marked aril !abeledlplacardeo, and are in all respects in proper condition for transport according to applicable ultemadonel and natural governmental regufatxxu if export shgrnert ane I am rte Prr^,xy <br />Exporter, l certify that the contents of this consignment conform to the terms of the attad ed EPA Acknowledgment of Consent <br />i certly that the waste minimization statement cdendfied in 40 CFR 262.27(a) (H I am a large quantity generator) or (b) (II I am a small quantity generator) is tr E <br />ars erors 1WTyped Name gra re za <br />16. Intemadenal Shipments <br />❑ <br />Z Import to U S C Export from U S Pon of entryiexd <br />Transporter signature for exports only); Date eaving U S <br />LU 17. Transporter Acknowledgment of Receipt of Materials <br />~ra j1 PrintediT <br />?Spprter Med Name signatUry j( r* err Year <br />O l n I <br />CL r' •. f <br />in - <br />ahansporter 2 Pninle*7yped None Signature a r—, :e& <br />8. Discrepancy <br />13a, Discrepancy Indication SpaceEl <br />CtiaQuantity❑Er�Type `1 Residua LJ Partial Retecnon Fuu Rewt;,wr. <br />Mandest Reference Number <br />� 1 ab. Alternate Facility (or Generator) US EPA 10 Number <br />J <br />(j <br />a <br />w raali s Phone: <br />w 16 . Signature of Alternate Faalily !or Generator) Mom Dav vew <br />Q <br />2 <br />N <br />19. Hazardous Waste Report Management McMW Codes (i e., codes for hazardous waste treatment, disposal. and recyGmg systems) <br />W 1 2. ] 4 <br />O <br />20, Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br />Pnnfed/Tvped Name Signature Month Da) Year <br />EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />