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429779 <br />Please print or type. (Form designed for use on elite (12-puur) typewriter.) Form 1290848 B No. 2050-0039 <br />UNIFORM HAZARDOUS WASTE MANIFEST 121. Generator ID Number 22. Page t2 23. Manifest Tracking Number Approved. <br />(ConInuatlon Sheet) CAROW213561 of 2 OM23625DAT <br />J,4 In��t�rs 96 <br />25. Transporter Company Name U.S. EPA ID Number <br />26. Transporter Company Name U.S. EPA ID Number <br />27a. 27b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 28. Containers 2g, Total 30. Unit <br />HM and Packing Group (if any)) No. Type Quantity WtNoi31. Waste Codes <br />. . <br />x r <br />• - .. v4avr ua avu,-vnvnn ate, p�p..7, tG, 9-U�-3 :TTVII" <br />1A� <br />... <br />0-l" <br />r <br />r <br />"MEN <br />FOM <br />BEEN <br />5-wom <br />boa <br />naeng instructions and AddItional Information { _ <br />(7) RIIBAI W IL-11 - IRG(153) TO%IC (LIQUIDS OITLT) - G=M=_ <br />1 ! <br />r __._AdmoMedgment of Receipt of Materials <br />Name Signature Month Day Ye <br />z 34. Transporter Acknowledgment of Receipt of Materials <br />PrintedrTyped Name <br />h <br />35. Discrepancy <br />J <br />U <br />ii <br />G <br />W <br />Q 36. Hazardous Waste Report Management Method Codes (i.e., codes for I <br />5) H141101 H141 <br />W <br />A111 H141 H177 11111 H141 <br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. <br />f treatment, disposal, and recycling systems) <br />1 H141 1(al H141 H177 (91 H141 <br />12) Hill <br />DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />