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Please print or type. Form des)gned for use on elite(124th)typewriter) Form Approved:OMB No. <br /> UNIFORM HAZAR)7®US 1•Generator ID Number 12.Pigielof 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST '•L,?,"1 15- <br /> 5103 <br /> JAN <br /> 5.Generator s Name and Willing Address Ge neratoes Sft'Address(d different Oran mailing address) <br /> $1*t}sox <br /> 1:20 Gt•#�tk.TeF t•4,` r' <br /> P.�. X +tis <br /> &T,=70111,Qtr, <br /> Generators Phone: RBti`?14 2t5f1: <br /> 6 Trarns)orter 1 Company Nie U.S.EPA ID Number <br /> �a0me W,f:4tmr:�lftiRE V <br /> El <br /> �tr1 <br /> .7..Tlansporter2 Company Name, U.S.EPA iD Number <br /> -NOV-2,0 2015. <br /> 8' @3!P 1FtQ.M0tqr.Ar U.S. D <br /> P 10 EPA INumber <br /> L-M-1 2�a5 <br /> = ---- -- --- -- -- <br /> €fl YMSFELD,� 9330 1;. ; ENVIRONMENTAL <br /> r,' ®EPl4RTMEIT <br /> F s Phone ;• . <br /> ga •Pb•U.S.DOT (s+dtng Proper SMp{ng Name Hazed Gass ID Number r f0,Cor>>amers, .,. 11 Tp1a1 12 UnO. ; <br /> HM-.-and Padeng (O any)) No. Typo Quantity WNW. 13:Waste Codes <br /> w 2. ; <br /> 3. <br /> 4: <br /> 14.Specicl Hatnddr�instruGtons aiud hr[ormation /,��P f l e_7a # (��L _�v j <br /> t3 t9s S71 411iS:IWr �f ® Vic;r�'t c• <br /> 'NEAR GLWES <br /> 15. GENERATOR'SIOFFEROR'S CERTtRCAMON;1 hereby declare that the contents of this const nmetnt are fully and 8ccuralely described above by the proper shippl"name,a[d'are classified,packaged, <br /> marked and labeledfplacarded,and are in all respects in proper conMon far transport according to applicable international W national governmental regulations.if export shipment and I am the Primary <br /> J Exporter,ICU*that the contents of this co*mrent conform to the terms of the attached EPAAclmowfedgment of Consent. <br /> I certify thal the waste minimiza�n statement kterNiffed in 40 CFR 262.27(a)(d I am a targe quarAy gs nerat2 j ot�(b)(if l am a small quantity generator)is true,; <br /> Geoe farslf7freror s PtlttedfTyped Nave j SignnaahRe Month Day Year <br /> .� 16,International Shipments <br /> ;❑import to U.S. - ❑E)rpo"U.S. - Port of entrylwft� ... <br /> Transporter sfgnahae(for aborts only): -1 (rate leaving U,s <br /> OC 17.Transporter of Raceipt of Malerials ' <br /> T yped V <br /> ( Sii;inafin J�t month Day Yewca / <br /> 50 <br /> Transporter 2PrirdedfTypedName r Signature __. .. Month Day Year <br /> 18.Discrepancy <br /> 18a.Disc epency Indication Space ❑ Quantity ❑Type ❑Residr e ❑Partial Rejection ❑Full Rejection <br /> Madfest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> ii Fidity'sPhone: <br /> q 180.Signabine of AOemate Facility(or Generator) Month.. Day Year <br /> x . <br /> 19.N Waste Re�24 Management Method Codes(Le.,codes for hazardous waste halment,disposal,and recycling systems) <br /> 1 l 2. 3. 4. <br /> 20.DesigretWedRy Owner or-operator.Certification of recelpt of hazardous materials covered by the manifest exceptAst 1 bi Item 18a <br /> Priated/6ypedN)am� ! f a No t <br /> -:./ I ,1r,1 yrs ! (1� r•,fes, .. j rr' J f t <br /> -PA Form 8700 22(Rev.3.05) Previous edifiims are obsolete. 7 RHSPOR>I' R'S COPY <br />