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i <br /> r7 <br /> e�desf ad for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2Q50-0038 <br /> i.Generator ID Number 2.Page 1 of S.Emergency Response Phone 4.Manifest Tracking Number <br /> R sous ;4 0101' } dzF3• 7 � � � J J K <br /> [Fk <br /> Name.and Mailing Address �t E 8k; � !e r4 3€` } Generator's Site Address(if different than mailing address) <br /> �t�"#•k��e"�.�73Yf*2�J I��r�>;PS::� �tvF����9§'��4%�!"t�+`t4.r� <br /> AW <br /> ratoes Phone: <br /> s�odor i Company Name l(�t 11dtto� (? 5 per U.S.EPA[D Number p <br /> 7. <br /> Trans$porlor2-Company Name U.S..EPA IDNumber p�" " f <br /> ° ltxt'F'r m! ollw��,Rl rvi"at-,tow,S 3F 7'�4:�i=n'r '.:.•}>:3.1-02.9"II:,eA�'33 <br /> 8 DasIgn'ated F ci%Name and SmteAddress U.S.EPA ID Number <br /> r ar VrFR atr`� atm€ f,►�3,t,.>, VWK10-135211 ill <br /> ci <br /> Si�i"(Pt Fol lyWi' i''p,''RP <br /> Factilily`s Phone: <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(if any)] No. Type Quantity WLIVol. <br /> Q <br /> 4. <br /> tD <br /> 3. <br /> 14,Special Handling instructions andAddilional Informaitl'Se - <br /> 1�.° iJ.x13(d:r�a�i �:F4E'4. i-4Y asf'�:3�r'y]T,lg�fi�- a ] "•i f <br /> 15. GENERATOR`S10FFEROR'S CERTIFICATION: 1 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 Iabuledlplacarded,and are in all respects in proper condition for transport according to applicable intemaiionaland national governmental regulations.if export shipment"and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the forms of the attached EPAAcknowiedgment of Consent. <br /> 1 certify that tt a waste minimization statement identified In 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(ifl arn-Arnail quantity generator),fs true, <br /> Generalof s/Offemes PdntedlTyped Name Slgnaluro . � '' Month DayYear <br /> zi 16.International Shipments <br /> i- ❑Import to U.S. ❑Export from U.S. Port of enlrylaxil: <br /> Transporter signature(for exports only): Date leaving U.S.: - <br /> qi 17.TranspoderAcknowledgmentof Receipt of Materials <br /> Transporter 1 Printedffyped Name S" Signature Month Day Year <br /> b. L g �` 7 c <br /> d �''L�.' t' Ss i-.`.�r a b ;,K-ply Q. <br /> Transporter 2 PrinledfTyped Name Signature Month Flay Year <br /> r�- <br /> 16.Discrepancy <br /> 18a.Discrepancy Indlcalion Space ❑ quantityyp J j <br /> ❑T e ❑Residue partial Fla ectlon ❑Full Re edlion <br /> Manifest Reference Number: <br /> 18b.Alternate Faclliiy(or Generator) U.S.EPA 10 Number <br /> J_ <br /> 4) <br /> 1y Facifity's Phone: <br /> LLI <br /> I8c.Signature ofAltemate Facility(of Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as riled In Item 18a <br /> PrintedlTyped Name SignatureMonth Day War <br /> FPA Form 8700-22(Rev.3.05) Previous editions are obsolete; -TQ R'.S BNOT IA COPY <br /> k <br />