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�z <br /> Please print ortype.(Form designed for use on elite(12-pitch)typewriter.) '€ Form Approved.OMB too:' <br /> 1.Generator ID Number 2 Page 1 of 3 Emer enc Res oPhone 4 Manrfest•Trark€n Number. <br /> UNIFORM FtAZAR�QUS g Y phse , <br /> WASTE MANIFEST t;: -� r •" �.� <br /> 5 NY <br /> Generator iJame:and a€EtnQq Addresg "Geriera#ors Site Address(if differerit than mail€ng address) <br /> S;1>rs3 t4d, Nt.:i-fi'.. . ,?s�J;ae.1.. ;`{„ t_i�-, <br /> r <br /> Generators.Phono: + <br /> fi TransporteY106rnpanyName s U,S EPAiilNumber <br /> 7 Transporter 2 Company Name; ( U.S EPA ID Number <br /> y i <br /> >r",1_11i <br /> e fir.. ,�...�:,.. �,...f�', �••.i r �L-. 1 <br /> 8 <br /> Des€g(tatedgl€tyNametand5lsddiess ' a U.S EPAID,Nombtr r <br /> F<a era.. <br /> Facd€fy`sPhone: <br /> , S�t <br /> ga• 9b U S,DOT_Descnpfion{€nclutl€ng.PrPer Sh€piling Name:Hazard Class ID Number;. 30..Cpntainars 1:1 Total,. Codes <br /> HM-1 12.Un€f gg iNas#e and PackingGroup(ifany)). <br /> .No. Type Quan% Wt.Nof, <br /> a <br /> Uj <br /> �. 2. <br /> LU <br /> 3: <br /> ?4 Special Mat#dlrngJnstruci€ons a dAdd€fional lnformatton <br /> i'¢ <br /> 15 GEaIir NATO.,SIO�FEROR-S CERTIFICATIDN l herebydeclare,that the contents of th cor'sigrimant are fully and aceurately-descrit ed above by the properstiipping name;and are ctass€fled gq`ka ed " <br /> M. and tabeledlpiacardeif and are m all respects€n proper condition for:}tansport according to applicable international and naflond governmental regular oris.If export shipment and],am the Primag' <br /> rY <br /> Expoiter I cert€fy-that the contend of this consIgnment coriform;to'the terms of the attached EPAAcknowfedgment of Consent, . <br /> I cerfifjYthat the waste m€nirr izat€on statement€dentifed€n,40-CFR 282.27(a}.(f I am a large quantity.generator)or(b)(if i am a small quantity generafvr)tsfrue: <br /> Generator'slOfferors PnntedFrypec Name(y{$; S€gnature s MOF ,Drq. 7gYear <br /> . :� �'",M f�E.R�� +,w .�J�F �w`.�f��,r ��'�r ,� :,r„»..,.`.w.rNw+na «�:,,w,,.,,w.,-„n..- � 'a„,•.` . P �' .�. . <br /> lniamal€onal5hiprtfents p ❑ExportframlJ:S, Port of. <br /> FZ.` - ❑ir1-I ort t0 U)S - - . <br /> 5 Transporter s€gnature{f oerts._only) Date leaving U.S.:. <br /> 17 TmnsporfecAcknowfedgment of Rece€p#of.Materials <br /> �;Transporter l PrinkedlT erne Signature: � Month Day Year <br /> O' _ <br /> Transporter 2 Pnhted!Typed Naive s <br /> . t 5 Signature Month Day` Year <br /> i 'f t Z <br /> ` i V <br /> k <br /> '; 18 DEspreparicy ..: ; <br /> 3 <br /> 18a Discrepancy-iridicalioh Space _ �` <br /> Quantity Type . D Residue ❑Partial Rejection ❑Full Rejection <br /> Man'rfest.Reference Number. <br /> 18b.AlternataFacility{or Generator} <br /> U.S.EFA?t3 Number' <br /> FacT.Y.s.'P.hone: .' <br /> �` 18c,signature of Alternate Faciilty{dr Genetatpr) <br /> Month .,Day. Year;: <br /> yLUz: <br /> 1g Hazardous Waste;Report Management Mathad Codes:(I @,,,codes for hazardou6.wv ste.treatment disposal andpecyeling systems) <br /> ILI`1 .. - <br /> 3: 4. <br /> 20 Designated Fagility;Owher or%erafot:Certification:of receipt of hazardous materials covered by the manifest except as rrt€ed,in ltem18a .. <br /> PrmtedfFyped Name <br /> Si nature <br /> g -Month Day <br /> EPA Form 8700 22(Rtw:3 05) t?tevlous'editions-are obsolete.. ��n e;__,__._-•- _-•_-- <br />