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T <br /> 'lease print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1:Generator ID Number _ 2.Page 1 of 3.Emergency Response Phone rol2l'67144 <br /> Manifest TrackinNumber WASTE MANIFEST ( l ::t7�'� 1 ' 1( t. { i t f JJ K..`;;,: <br /> 5.Generators Name and Mairing Address Generators Site Address(if different than mailing address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name ' U.S.EPA ID Number <br /> t:'t,f li n E�)l:iRrJ(v4r1E l�kf.'I tz:+'tiGE i <br /> -a,7101`4 3f1 t?iL! <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Fad*Name and Site Address R:Z.r n- C`1'ft.fgr3'df: 1'li; GE f?'`fOf U.S.EPA ID Number !, PVC <br /> V a, <br /> � <br /> 1t�°9T^na19»f4EP00,ry 9500 <br /> Facilitys Phone: <br /> 9a 9b.U.S.DOT Description(inducting Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.T0131 12.Unit 13.VJasle Codes <br /> HM and Packing Group(darty)) No. Type Quantity Wt Vol. <br /> L.£ - ! 7L'i <br /> o a l <br /> z 2. _. <br /> LI <br /> r.7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> :,'moi) EFi$rft7i r: L bra t <br /> K414 L I.111:;'i.0 elf:7t%?ttN£7 AND US;! afrFfity%ir.40 FPir <br /> E P. C0f4TlR.ACT4F' ftAMCItb tThi,dF?tildtkt pStf�L S fn iC,E <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fu9y and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledfplacarded,and are in al respects in proper condition for transport according to applicable international and national governmental regdlations:If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdmowiedgment of CorsenlL <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(d 1 am a large quantity generator)or(b)(d I am a small quantity generator)is true. <br /> Ge`emtorslOfferors Printe&Typed Name Signature Month Day Year <br /> ,•i •1 .I(r l ,ra <br /> 16.International Shipments <br /> F 0 Import to U.S. ❑Export from V'S.- Port of entry/exit <br /> '-s Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedTTyped Name Signature Month Day r Year_ <br /> ZTransporter 2 PrintedlTyped Name r Signature I Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> ra+ Facility's Phone: Month Day Year <br /> CS 18e.Signature of Alternate Facility(or Generator) <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and recycling systems) <br /> 0 1 2. 3• 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />