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t <br /> 1 <br /> Please print o m designed for use on elite(12-pitch)typewriter.) Form.Approved.OMB No.2050 OD39 <br /> 6106HAZARDOUS HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone b.Manifest Tracking Number <br /> WASTE MANIFEST CPJ.,M1 _117-39_3!3 '� :fu 123 DAT. <br /> 5.Generator's Name and Mailing Address ri;if AnMwy(=;!wes Generators S•ste Address(if different than mailing address) <br /> 5limU Caen r, 1'76,Mcw,.�+�# <br /> Teats3 } ii' 3 hg F7in� 'F <br /> Generators Phone: € n' V 1402 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> (PIr �'i�)kC1�4 es�,. a'irf'd�$t<���t�:� (�'�)����:'.•�1f��� �� " ��'�} � ��."i�`I�'�'sfA!?� <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Des�igxnpated Facility Name and Site Address U.S.EPA ID Number <br /> ewi <br /> 1902i ewky4sirla ROM <br /> Facilitys Phonefl 52- <br /> g <br /> 9& <br /> ga- 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(it <br /> �a�ny))x a t p q g �p S No. Type Quantity Wt.Nol. 00 <br /> kb,�I.sit',.�',�t.e�x"rtY 933,i�� �E}; u1�it A��e vkSsiQt.f i, �l,.t005 <br /> d.-,4 q <br /> w <br /> RAI <br /> C7 <br /> ggtit :� <br /> a. <br /> 14.Special Handling Instructions andAddiiiorial Information <br /> DwaliumA 001209 SAw MT lor V,5 81 89 <br /> I,'k mRk=0811-3217,31 DAG ERM 54 <br /> 15. GENERATOR'SfOFFEROR'S CERTIRCATION: 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 In all respects in proper condition for transport according to applicable international and national governmental regulations.if export shipment and I am the Primary <br /> Expbder,l oertify that the contents of this consignmentconform to the terms of tho attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 282.27(a)(if I am a large quantity generator)or(b)(if]am a small quantitygoneralar)is true. <br /> Generatoes/Offeror's Prtntedlfyped Name Signature Month Day Year <br /> J 16.International Shipments El Im rt 10 U S <br /> Po Export from U.S. Port of entrylexit: <br /> -- Transporter signature(for exports onift Date leaving U.S.: <br /> Ix 17,TratnspiodorAcknovdadgment of Receipt of Materials <br /> LLI <br /> Transporter 1 Printed/Typed Name Signatum Month Day Year <br /> co <br /> d Transporter 2 Prinledffyped Name 6' Signatu Month Day Year <br /> F— <br /> F <br /> 18.Discrepancy <br /> 18a,Discrepancy Indica€ion Space <br /> [IQuantity ❑Type 1i Residue ❑Padlat Rejection C -F-QI Ro)ection" <br /> Manifest Reference Number: <br /> 18b:Alternate Facility(or Generator) U.S.EPA 10 Number <br /> 1 ' <br /> U <br /> u-. Facility Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 1-- <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,erodes for hazardous waste treatment,disposal,and recycling systems) <br /> v 1. 2. 3. 4 <br /> ti. <br /> 20.Designated Facility Owner or Operator:Codification of receipt of hazardous materials covered by the mapifestexcept as noted in Item 16a <br /> PdntedlTyped Name Signature Month pay Year <br /> EPA Farm 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />