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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS r'.� -p a� �. <br /> WASTE MANIFEST y� y ��' 4 2 JJ K <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Ki t.1TO:+kAJD 17'.I ICK PLS,.A. <br /> 1474;]0 THORNIVON R0. <br /> 1.001,Cis. W.442 <br /> Generators Phone:`3r1>der <br /> 6.Transporter 1 Company Name 1 U.S.EPA ID Number <br /> PIC. A <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address NU.S.EPA ID Number <br /> t~F�lttSi FI��FRLtf+IPv1EAlTkt-;*'�Ft:'iry'E•� kAIC:. �'- <br /> [518 S0UiT"R#t4_R RU. <br /> ��3 SAGRAtvfEIVI'E?,G.� 45f3i <br /> Facility'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 Wt.Nol. <br /> 1. tit?i# F•.tiZs i;..,�ftFitt}l; ;lZ/? l �rit.ii't t( !_.L?FEfF[i1 <br /> Z 2. I <br /> w <br /> 0 <br /> 3. <br /> I <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> ;.Fi. f,04MA0Tt7fi: Rfia S ENVIftC_WttEMTAL <br /> !t{gLE Cd' SHOUI.b BE JRkJAIED A1,10 1J.-3;E/�P(=+ROVFD PPE <br /> 15. GENERATOR'SIOFFEROR'S 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 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 /> Exporter,I cedify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of 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 /> Generator'.s/Offeror's Printed/Typed Name -Signature Month Day Year <br /> 16.International Shipments <br /> z 1:1 Import to U,S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name 2 Signature Month Day Year <br /> O <br /> Q Transpo ter 2 PrintedfTyped Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> I8b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W 1 2. 3. 4. <br /> o ' <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 Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY <br />