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i,e e- ttrFS € 3'r CC ry . <br /> -0,BOX 4W SarmM <br /> Please print or type. Foran designed for use on elite 12 <br /> 9 ( ,typewriter.) <br /> UNIFORM HAZARDOUS 1•Penerator ID Number Form Approved.OMB No.2050-0039 <br /> WASTE MANIFEST j?+ '9 x~E" -= 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> ` .i <br /> 5.Generators Name and Maili Acif"ss � � 00 JJ K <br /> Generators Site AddrIsis(if different than mailing address) <br /> _ C W) �• �(h-� ,cam /..- <br /> Generator's Phone: <br /> 6.Transporter 1 CompanyName <br /> utib 1a'�i ve'!I}"w « wT U.S.EPA ID Number - <br /> 7.Transporter 2 Company Name ;uo�r-2.r.`s <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address - - <br /> I1j°t0 $Cnll I1`Yoy> U.S.EPA ID Numbe; <br /> I Facili 's Phone; "` �h�� "�_ •-� ^T" -M1— <br /> } <br /> ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class r T <br /> HM <br /> and Packing Group(If any)) Humber, Containers 11.Total 12.Unit <br /> 1.,•';,: w (r`*' �:��! 1 rte+ _. T Type Quantity WLNoL '3.Waste Codes <br /> ui <br /> 2. <br /> 14, pedal Handling Inshuctions and Addilional Infommtion <br /> 5. G`sNERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the cnntOWS of this consignment are fully and acrurat:'z described above by the proper shipping name,and are classified,packaged <br /> ^ marked ani labeled/placarded,and are in all respects in proper condition for bansoori according to applicable international and crui and nelanal governmental regulations, <br /> i F-xPoeier,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. if export shipment and I am the Primary <br /> I certify that the waste minimization statement identified in 40 CFR 261(if i,r; o;,"ole quantity gene,etr.,r r' <br /> yr *rotor rors;Prir lTypied Name - )or(L ,iI+m y small uan6ty generator)is true. <br /> Sig re <br /> ;i -4 �._� " •+ -:.a f forth Da Year <br /> nerill <br /> y( Impo t to U.S. L_l Ex rt from U.S. <br /> an�rlattue{for expurts only):. po I'u�.,f entry/exit <br /> Date leaving U.S.: --------- <br /> r AcAr;,-?ed - ----- <br /> gg gment of Receipt of Materials <br /> I?F PdntedlT' Name --- _---__ <br /> Signature lid <br /> s. �,.....,�,.., t<r';�s"^;G�- �•;.�s.,t, .. 1 .. .��onth DaY Year <br /> .fd.I Tr3rrsporter 1 PrirKedlTyped Nam3 -_ � rem/ �° <br /> Signature .— <br /> _ Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy r.1dieytion Space �TM <br /> Quantity l...J fyr,• <br /> ❑q - --� <br /> II Residue ❑Panial Rejection i r;.:elec'tiort <br /> I..: 1,9bAlternate Facility(or Gererator) --, -., ,, .. Manifest Reference Number. <br /> V <br /> U.S.EPA ID Number <br /> t'a= Facility's Phone: <br /> 18c.Signature ofAltemate Facility(or Generator) - _ I <br /> ZMonth Day Year <br /> N19.Hkzardous Waste Report Management MethodCodes(i.e.,codes for hazardous <br /> LU waste treatment,disposal,and recycling systems) <br /> 1 <br /> O 2. 3. <br /> 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 /> Printed/Typed Name <br /> Signature <br /> Monfh Day Year I --- <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />