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Please print or type.(Form designed for use on elit (12-pitch,-,rawriter.) '"'`-'*'c" r . ' i:. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Nu er 2.Page 1 of 3.Emergency Response Phone 4.Man <br /> ifest Tracking Number <br /> WASTE MANIFEST 1 l} t)Q? 0$ 0!} 4 '1 i (800)X183 37 lig V V 7 4 6 3 J 4 7 FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> lltocktort 1151) tAa)Wtiieh f:c ! <br /> 1M.414. EI 1'tttal 011-tyH tuft).1'A (fit 1i1.�tfyw1-t .162t Ukoo�tskW Road <br /> ''ur'w4Morl..('.A 55205 V t <br /> Generators Phone: Eno';rIL 110-i -1 O7 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> +tvir4at�r4tNt!w*J �raicas irts M A DO'1 9 3 2 2 2 0 <br /> 7.Transporter 2 Company Name MAY 072014 U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> deatt H w bor 5 t+ein.,iD.se t L(: ENVIRONMENTAL <br /> ii421aetrMtrsaai2(ted HEALTH DEPARTMENT <br /> S '�. V t• fy 3 ; I_ t:) <br /> an Juse.i-A 9b l.3J <br /> Facility's Phone: u + -C412 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1.NOM WfRA IWARI(X111S A3'ru S(A.IDS.(011tY IX8114151 352 <br /> LLI <br /> LU <br /> 2t?. 51 <br /> el r <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Informtion <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 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 labeledlplacarded,and are in all resp cts in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consign ent conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement ide ified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generators/Offerors Printed/Typed Name Signature on ay ear <br /> -J16.International Shipments <br /> F- ❑Import to U. ❑Export from U.S. Port of entry/exit: <br /> Z <br /> Transporter signature for exports only): Date leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> Ll <br /> Transporter 1 Printed/Typed Name 1gnature.._:-..- Month Day Year <br /> QTransporter 2 Printed/Typed Name Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Partial Re ❑ 1 <br /> ❑ Quantity El Type Residue Rejection Full Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Q <br /> r+ <br /> Facility's Phone: <br /> Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Cod (i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. }i4U 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification c f receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are bsolete. GENERATOR'S INITIAL COPY <br /> f:i0m t1,afhw,c#tax me pt,Irr;it06 If or 41a W411 atCop t itif viii oe the geItvrFYer f4 51NpptrsP,` <br />