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Please print or type. Form designed for use on elite(12-pitch ewdter. Form Approved.OMB W. <br /> UNIFORM HAZARDOUS 1.Gererelor ID Nuntier 2,Page 1 of 3.Emergency Response Phone 4. nifest Tracking4783029 <br /> �Numbe(r� E <br /> WASTE MANIFEST CF.tt 3£� .7 ! Q'S19441_57 i•1-,O`-�" 8 V JA. <br /> 5.Generators Naand Matting Address Generators SbAr�ess(t different than <br /> Nam mailing address) <br /> P.O.Sok * iiT71''S,i•. <br /> 5"MCKTOK GA SWOB <br /> Generator's Phorre: 2> 1 X73 d-elf � U.S.EPA 9 Number <br /> 6.Transporter 1 Compa ny Name ' <br /> 7.Transporter 2 Company Nam U.S.EPA ID Number <br /> DV <br /> 8. aced Fa,in'�Ityy Name ami Site Address <br /> U.S.EPA ID Numb <br /> �Afi;~1R5#TfEf.-D,TA dtlSMR IMt:. t•w rc.^c.{,- <br /> NVIRONAENTAMO E. eRufDAGIE t <br /> »AISe !`IEI.D CA 2.33trTI I'DEPARTMENT <br /> _ _.__Facititys.Pryoie;. . <br /> - <br /> _._ . <br /> . <br /> tO:G 11.Total 12.Unit 13.Wade Codes <br /> 9b U.S.Dor pesthiptcorn(ehrrig Shipping Norma,,Hazard Class,ID IVum6er: ._ .,- Quantity WtNol. <br /> .- <br /> aidPaddag Vany)) Type <br /> - No. # <br /> o 1. fJCP.I RCRA 4•tA,ZAPD'OUS,''VAS F OLID iCILY :A-5�iKE-C-tlf�aj EW /`��� F �a <br /> r_ (V <br /> LU 2. <br /> ru <br /> 3 ) <br /> r <br /> ' l <br /> 4. <br /> 14.Special Handling lcetructiorts and Additional Information <br /> a <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are filly and accurately described above by the pmW slipping name,and are classiffed,packaged, <br /> marked and labeledlplocarded,and arein all reacts in proper condition for transport according loapplicable iRenetionalard rational governmental relations.t export shipment and I am the Primary <br /> Exporter,I certify that the contorts of this catsigronent conform to the terms of the attached EpAAcknw&dgmenl of Consent <br /> I certify that the waste minimization statement Identified it 40 CFR 262.27(x)(I I am a large quantity generator or N(dI am'a'`smatl quantity gernerato)is true. <br /> Generaidal0flemes Print ed/T orae ( _ ' th Day Year <br /> 14 <br /> -1 116.International Shrypments ❑Import to U.S. ❑Export from U,&:'- Port of entry(exit <br /> Transporter signature(Mr eproors only): ;-' Data loving U.S.: <br /> W 17.TransporterAcknowlellirnent ofReceipt of Materials r' Monti Day Year <br /> Transposer 1 PcittedfTyped N 4 4 <br /> L��� � "'7 �Ci <br /> 7r J <br /> tat Transporter 2 PdntedlTyped Nave lure tRonth Day Year <br /> H <br /> 16.Discrepancy.... <br /> 18a.Discrepancy indication Space ❑ Quantity ❑type ❑Residue ❑Partial Rejection ❑Fill Rq*tion <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Fadi ys Phone: Month Day Year <br /> WE Signature of Alternate Fadlty(o Generate) <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codas(.e.,codes for hazardous waste treatnant,disposal,and recycling systems) <br /> C 1 p f' 1f t 3. 4. <br /> ..f j _./ <br /> 20.Designated Facility Owner or Operator:Ceri6eation of receipt of hazardous materials cev,red by the manifest except as nded in Item 18a <br /> Month Day; Yaac.- <br /> PdntedfTyped Names I f' lrr_ .� bgnalure .. <br /> •� 1 �.... <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY <br />