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Please print or type. (Form designed for use on elite (12 -pit <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />WASTE MANIFEST 1 tiro t,f,j <br />5. Generators Name and Mailing Address <br />r':111. 1101111,1-4 1'0-nk l.zrr+," <br />M00,tvt-1, (`0. ` S).Ok <br />Generator's Phone: <br />XW <br />T <br />{;tom k atilt-4td C-ordow& , LTA,' <br />�.'t BR:.'.► t1FlT,ite. T�c��-1f: "tttabd <br />I1otu_ttit, x'rrt•tiav�r , c'1, M!+'1491 <br />Facility's Phone: { ; . 't ►# �# i° s <br />ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />1 i�cn. 13saf a WAX11 a Lol.j.t! <br />LU <br />z 2. <br />Ik1AVyA [SA,r21rJ=tarcn«at.4r fi4:p- .t -it -_f.�:�s,t� <br />I : 3. <br />4. <br />Form Approved, OMB No, 2050-0039 <br />1 of I J. Emergency Response Phone �M— <br />g Number <br />8(It61 �.i-� � U 72 FLE <br />EPA <br />i-4p000070SAe <br />ID Number <br />10. Containers 11. Total 12. Unit <br />No. Type Quantity Wt.Nol. 13. Waste Codes <br />t ; <br />GENERATOR'S INITIAL COPY <br />lj it�.lt"�2.�; C'ji(y-• [i-y'1�71B�,aPb;'_.t,�.G.._.. <br />� rc�tie#r..t Iii�u�.9�rrx : 17:1:i�i <br />15. GENERATOR'S/OFFEROR'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 <br />applicable international and national governmental regulations. If export shipment <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />and I am the Primary <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator orb if I am a small quantity <br />Generator's/ ) O ( q ty generator) is true. <br />erors Printed/Typed Name igna ure <br />i <br />ont ay ear <br />�j 16. Intemational Shipments <br />F' ❑ Import to U.S. ❑ Export from U.S. <br />Port of entry/exit: <br />Z Transporter signature for &1:1:11:11 onl ): <br />W 17. Transporter Acknowledgment of Receipt of Materials Date leavin U.S.: <br />I ransponer 1 Printed/Typed Name <br />gnature <br />0 <br />a <br />on ay ear <br />r» t' <br />Q Transporter 2 Printed Typed Name I <br />gnaturp <br />Month ay ear <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑ Type ❑ <br />Residue ❑ Partial Rejection <br />❑ Full Rejection <br />H 18b. Alternate Facility (or Generator) Manifest Reference Number: <br />U.S. EPA ID Number <br />U <br />Q <br />LL Facilit 's Phone: <br />w 18c. Signature of Alternate Facility (or Generator) <br />ZMonth <br />Day Year <br />9. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. <br />IP <br />3.4. <br />0. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />nted Typed Name <br />Signature <br />Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous <br />editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />