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Please print or type. Form designed for use on elite(12-pitch)typewnler i Farm roved.OMB No.2050-0038 <br /> UNIFORM HAZARDOUS 1.General ID Number 2.Page l of 3 Emergency Response Phone 4.Ma�'nlije(s"t�Tracking Number^�y {{�� C{�[1� <br /> WASTE MANIFEST r,:"' ^`•' 1 0`�' `�• S <br /> 5.Generators Name and Marling Address General Site Address(it dffle- than mailing address) <br /> f�TTN <br /> Generators Phare: <br /> 6.Tmisport Company Nerm ' ^.;+ U.S.EPA ID Number <br /> 7,Transporter P Company Nance U.S.FPA ID Number <br /> 8.Designated reality Name and Site Address - U.S.EPA ID Number <br /> IJFAT € fne + <br /> Facilil IsPhore: <br /> qa So US,DOT Desuption linduairg Proper Shipping Name,Hazard Class.ID Number. 10.Contto is 11.Tota1 12.thdt 13.Waste Codes <br /> HM and Packing Group(it any)) No. P,Tie Quantity WLML <br /> t .. Pa,..5 1 <br /> 1.. a <br /> aFttf (iFt'+.iPifii tL. ;IFIrPfC'C:r'ai,l=i.l;v ;1 : <br /> STT t . .rm1 <br /> _ <br /> 4 _..:.; <br /> 14.Sped2l Ha inglnslnidi=and IL'anallafambbon _. , .. . <br /> 15. GENERATOR'SIQFFEROR'S CERTIFICATION: I hereby declare mat me contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged. <br /> marked and labeledlpFararded,and aro in all respects in proper condition to transport according to applicable imemational and national govemmental regulations.If export shipment and I am The Primary <br /> Exporter,I Wari"at the contents of this consignment conform It,the terms of the attached EPAAcknowledgmenlof Consent. <br /> I cefafy that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)IT am a small quantity generator)Is true. <br /> Generatorsl0flemes PnntedfTyped Name Signature Month Day Year <br /> 1t <br /> ------------------ <br /> 16 Inlemabooal Shipments ...._. _..— <br /> i— EJImport ro U.S. ❑Export ham U.S. Pat of enhyfexic <br /> 2 Transporter someone(taexports only): Data leaving U.S.: <br /> CZ 17.TranspoderAchnowledgrnentof Receipt of Materials <br /> m Month Day Year <br /> K Trarsporer 1 PnMedrryped Name Signature <br /> O <br /> MTransporter 2 Primsee typed Name Signature Monty Day Year <br /> Q <br /> K <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Irdwgon Space ❑ Ouani ❑Type ElType ❑Pam Rejection ElFull Rejechan <br /> Wei Relae.Nmt>bar: <br /> 1ab.Alternate Family mar Generator) U.S.EPAIDNumber <br /> J <br /> V <br /> rani FaaliTy'6 Phone: <br /> aw 18a SIg E'alAlternate Facility Jay Generator) Month Day Year <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes fa haumous waste treatment,disposal,and reading syslons) <br /> 0 1 2 0 4. <br /> 20.Designated F..*Oxner or Operator;Certification of recelpt of hazardous materials covered by the manifest except as noted in hem 18a <br /> Il nWffyped Name Signal uray ear <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. _ GENERATOR'S INITIAL.COPY <br />