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!► <br /> .r designed for use on elite(12-pitch)typewriter.) . <br /> 1 � <br /> 1.Generator ID Number Form Approved,OM13 No eoa 0{139 <br /> �RDt][!S 2.Page i of 3.Emergency Response phone 4.6rtfpst Tracking Number <br /> �fiFEST. <br /> ?Ni— dr a 3 0 ..677 DAT.. <br /> a Name and Mailing Address cr �Rrr �;<y���'��bba 'Generators Site Address(if different than mailing address) 9 T <br /> AP 5 �Iry 1 CFm-3 <br /> z� •� --�ratoes None. x i s° gA Y <br /> ransporler l Company Name <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name 19747 <br /> U.S.EPA ID Number <br /> 8.Dusignated Fadl#ty Dame and Site Address <br /> U.S.EPA ID Number <br /> o <br /> ew <br /> � fi:� a .. 3s`�'w '�x7 IIa <br /> Facility's Phone - ar <br /> 9a. 9h.U.S.DOT Dascription(including Proper Shipping Name,Hazard Crass,ID Number 10.Containers <br /> 11.Total 12.Unit <br /> HM and Packing Group(If any)) No. Type quantity VVt.1Vol. 13.Waste Codes <br /> q#' oC+ tZ4 , <br /> Lki <br /> Z 2. a+f <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling lotructions and Addit€onal Information <br /> ir,�as?' zA,»r � s• '.n;�'xr•ffils' 7-+fu <br /> 51t117 ) r f•yr; <br /> 15• GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of ibis consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labaledlplacarded,and are In all respects€n proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform id the terms of the attached EPAAcknawiedgmentof Consent. <br /> I certify that the waste minimization statement Identified 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 /> GeneratorsldfferolsPrintadfTypedName Signature' Month Day Year <br /> —� 16.International Shipmanis <br /> ❑Impart to U.S. ❑Export from U.S. Port of entrylexit: <br /> z Transporter signature(far exports only): <br /> Date leaving U.S.: <br /> i7.Transporter Acknowledgment-of ReWipt of Materials <br /> W_Transpor{er 1 PdnledlTypad Name Signature <br /> , MonthDay Year <br /> C. Transpprfur2PiinfedltypedName Signature Month Day Year'. <br /> r-- <br /> 18.Discrepancy <br /> f8a.Discrepancy Indtcat€on Space ❑ quantity ❑ e <br /> YP ❑Residue ❑Paitiat Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18$.Aliemate Facility(or Generator) U.S.EPA IQ Number <br /> .r <br /> 0' . - <br /> Facitlty's Pho6o: <br /> F "18a.5€gnafute oFAtfamateacltity(or Generator) Month <br /> Day <br /> Year <br /> w19.Hazardous Waste Report Management Method Codas(€:e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4, <br /> 20.Designated Facility Owner or Operator.Certificaf€on of receipt of hazardous materials covered by the manifest except as rioted in ltem.18a <br /> PrintedR'yped Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3.05) PreviOUS editions are obsolete: <br /> GENERATOR'S ( IAL COPY <br />