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Please print or type.(Fhmn designed for use on er'ite(92-pitch)typewriter.) Form Approved.011148.6 <br /> 1.Generator ID Number 2,Page 1 of 3.Emergency Response Ptrorte 4.Manifest Trarddng Number <br /> UNIFORM HAZARD ®� 0 JJ <br /> WASTE MANIFEST .AL-110n--o£`• Zit;-=t4 ";l <br /> 5.Generator s Name andEMalang Address <br /> • 4783 <br /> Generatoes Site Address(if differard than mailing address) <br /> set..K 7'•P.R{i, - t lid'.�.'7r`'.i3 t'�(.•.c.Sir <br /> f'.F�.f3rJ3i.t'r.+'i`� iki.`.•'�;Tt1I-t,ems. . � . <br /> Generators Phone: X +i t-�r &-2 - U.S,EPA tD Numt <br /> 6.Trerrspoderl Company Name' t aEtf.Rz!4 tF'?1ic' <br /> George W.! I - ' Ef"%,-'., <br /> U.S.EPA IO Numb <br /> 7.Transporter2 Company Name <br /> 8.DeNgnated Fila Name and SmeAddress _;' U.S.EPA ID Number. <br /> iE1Ai� i>»LD 7R.APJ�FIxfi fill(.': • <br /> i62t? <br /> E.BFiUNDAfoE tai ENVIRONMENTAL <br /> a4wen2FOM CA 933117 <br /> Fadtity's Phone ' <br /> a 10 Containers.- . i1.Total. i 12.Unit <br /> U.S:DOT Oascdption¢ndtadttg Proper Shipping Name,,Hazard Cess ID Nturt 13.Waste Codes <br /> HHly :.ata Padang Grp Of any!! No. Type Quantity WiNol. <br /> }. <br /> !Jf3i!i t�.'.R%�,NAZARi'�?tJ� ';"aA.yT'.� u... i <br /> 2. <br /> � I � <br /> n <br /> 3. <br /> 4. ` <br /> i <br /> 14.Speclai HandIng instructions and Additional information t , <br /> EF`.rj V.171 - <br /> INC-Alt GLID"'VES fv Ey^ut r <br /> 15. GENERATOR'StOFFERORS CERTIFICATION:1 hereby,declare that the contents of this consignment are fumy and acxwetely described above by the proper shippng name,and are rdassTied,pacmWd, <br /> marked and tabele4lacarded,and are In all respects in proper condition for uansspod accortrtg to applicable international and natal governmental regulations.m export shipment and I am the Primary <br /> Expaier,'I certify that the contents of this consignment conform to the terms of the attadted EPA mend of Consent. <br /> I certify that the waste minkritzallon statement klentilied in 40 CFR 262271x)(m I am a large cpran0►y generator)or(b)(If I am�stroll rpratitity generatrx is coat r � Day Yanr <br /> ,y �- <br /> GeneratorslOBerorsPdn <br /> ..r 16.International Shipments ❑ to U.S. ❑Export(torn U,Sr i' Part of entrylexit <br /> Transporter signature(for exports orgy): <br /> Dale teavng U.S.: <br /> U= 17.Transporter of R of Materials pp Day �Yp; <br /> a Transporter 1 PrkrtediT,,i*Name / <br /> f r'° � •L / a"""""rk Year <br /> Transporter 2 PdntedlTyped Name i J Sign i Month Day <br /> 18.Discrepancy <br /> 16x.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference somber: <br /> EPA ID Number <br /> 18b.Allemale Facility(or Generator) <br /> t4i. Facility's Phone: Month Day Year <br /> W i Sc.Signature of Atetrate Fadk(or Gorteratar) <br /> Q 3a <br /> Z <br /> 19.Hazardous a Kapott M agement Method Codes(i.e.,codes ler hazardous wase teallnent,disposal,and recycling systems) 4. <br /> r <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a .• Month Day Year <br /> Signature <br /> Prinledrryped NamO, 1 i•_ ! r f , f <br /> TRANS;?OFiTSE4'S COPY <br /> EPA Form 8700-22(Rev.105) Previous editions are obsolete. <br />