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Form Approved.'OM8 0.2050.0039 <br /> �U5 1.Generator ID Number 2.Page 1-of 3.Emergency Response Phone I.Manifest Tracking Number <br /> f.. <br /> k <br /> 67 <br /> Generators Site Address(if different than mailing address) <br /> and Maifing Address t TIIN;W 04T;7�F)s'F�� M � <br /> Coe <br /> 7.Company Name U.S.EPA ID Number <br /> porlat 2 Company Name U.S.EPA ID Number <br /> Igtrated Facility Name and Site Address U.S.EPA ID Number <br /> "aril+lyes Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 17.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type OuanGty wt./Vol. <br /> 3� <br /> w <br /> L � �r6 <br /> r� Z 2, <br /> L" <br /> C7 <br /> 3. <br /> 4. <br /> { <br /> 14.Special Handling Instructions and Additional InformationA <br /> 9 1x 80 155212 <br /> 05}t i vlfe;bititi„4t€yaa-A.e�21,?i Nxw ,€_Pad:�'01:1,y611U1031i '#_N4I#3gdt5&.Aiii CiF$awort#Yadd ora d 0fliltO4.1t%III wilkv.,'if1prfeb01S 04rya Ewaw h,Gil a�a. <br /> 15. GENERATOR'SfOFFEROWS CERTIFICATION: I 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!nail respects in proper condition for transport according to applicable International and national governmental regulations.It export shipment andl.am the Primary <br /> Exporter,t certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization slgemegt identified in 40 CFR 262.27(a)(if I am a large quantity generator)orlp)(if I gin a small quantity generator)is true. A./' <br /> f�� es]Offerors Printedffyped Name Signature•• -' Month Day Year <br /> 18.International Shlpments l <br /> ❑Import to U.S.= ❑Export from U.S. Port of entryleAt: <br /> ? Transporter signature(for exports only): Date leaving <br /> [1C 17.Transporter Acknowledgment of Receipt of Materials f. r <br /> Transporter 1 PrinledlTyped Name , Signature Month Day i Year <br /> CL <br /> Transporter 2 PriatedtTyped Name Signature Month Day, Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejectbri`•• ❑Full Rejection <br /> Manliest Refefence Number. <br /> 18h,Alternate Facility(or Generator) U.S.EPAID Number. <br /> U <br /> r4r_ FacilitysPhone: <br /> 18c.Signature ofAltornate Facility(or Generator) Munch Day Year <br /> a <br /> s <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4- <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardaus materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed NameMdnth Day Year <br /> Signature <br /> PY. <br /> EPA Form 8700-22(Rev.12-17) Previous editions are absolete. � � <br />