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Please print or type,(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MIANIF0 CAL( 65 c:�� s•:f, - = 1012473304 JJK, <br /> 5.Generaat/oes Name and Mailing Address Generator's SRe.Addres(sS(H�d f&wd uwn mailing address) <br /> ��yyVydy��k/".�nrf3�. i 1y41L���+41 W:1'y.1..1\S'.r,R• <br /> ty'ar�µ.�aa�'i'iw.}{P/yrV%1Yrl{ ?I I:i1N1�g1Y. <br /> GaheralDes Phone. ami <br /> 6.Transporter 1'Conmpany Nannie U.S.EPA ID Number <br /> jetw t SIM:LAW <br /> 7.Transporter 2 Company Now U.S.EPA ID Number <br /> 8.°.. abed F Name and Sge Address U.S.EPA ID Number <br /> MaTIAWER W; NOV 2 0 2015 r c + <br /> - <br /> _ <br /> 422 <br /> 7 <br /> 194VAORM5NTAL <br /> ga" 9b D S DOTI>escrrpfiat(4iclridin9Propar shgbpkmg Nane;;Razard,Class,NeftTH DEPART: ENTo..Contakters 11.Total 12,Unit 13.Waste Codes <br /> 'HMand.PaddngGroup(1a*) Ne. Type Ouanf2Y WWoI. <br /> bC ";t73a Rte PAZAIMUS AS,-f•E SOLID (ay aW8'iten61 <br /> s rj 1 <br /> 3. i <br /> 4. <br /> 14.Spedal Handling Instructions and Additional information <br /> +~t3oG 0171 fPJ`fCl f Pfar t+ # <br /> �uzUua�:� ���313—U3��7�•� <br /> 15. GENERATOR'StOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are tinyand aecivately described above by the proper shipping name,and are classified,packaged, <br /> marked and fabldediplacarded,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 /> BW%r,I certify that On contents of Otis consignment conform to the terms of the ahached ERA Acknowledgment of Consent <br /> I certify groat the waste minimization statement identified in 40 CFR 262.27(x)(If I am a large quantity generator) ,(b)Cdl ai(r a smag quantity generator)'s true. <br /> Generatom'slOfFeror s Prir><adllype�t�rrme L- ! 1` i, M ref' fila►! 14 <br /> ru rt t -------------- <br /> ..a 16.International Shiprrments Import to U.S.- El Erd from U.S. Port of enbylaxt <br /> � ❑ <br /> TFa mponei signature(for exports city): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> o� Transpq¢erS1 n LaRme <br /> Signature <br /> Day r <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Y <br /> Q •� <br /> 18.Discrepancy <br /> 18x.Discrepancy Indication Space 0 Quantity ❑Type EIResidue ❑Partial Rejection O Fug Rejection <br /> Manifest Reference Number. <br /> 18b.Ariemate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> U. FaralitysPhone: <br /> w lac.Signature of Alternate Facility(or Generator) Month Day Year <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> wo 1• � t 2• 3, 4. <br /> 24.Designated Facility Owner or Operator:Certification of cecefpt of hazardous matedals covered by the manifest except as riled in hero lea <br /> r6ded/Fyped Fume Sgnanxe- r tin qay . Ysam <br /> ! <br /> EPA Form 8700.22(Rev.3-05) Previous edi4mts are obsolete. ! ` (' TR',.'NSPOW ER'S COPY <br />