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Please print or type.(Form designed for use on elite 12-p1chtypewriter.) Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARD US 1•Generator ID Number 2.Page 1 of 3.Emeigerx y Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFEST Q---003 e,57 NO-5441—.�•€'h X-110 21 1' 014783146 JJ <br /> 5.Generator's Name and Mailing Address Generates Site Address{if different than mailing address) <br /> 'J:l..4" <br /> P.0.WX WINS T ISP fDlgi,t ii. <br /> 5TV4nf{Tf.�1,::?Zf ��J�3 ry <br /> Generator's Phone: ^t r�:ciT d- rYY <br /> 6.Transporter 1 Company Name U.S:EPA ID Nwnber <br /> Gil ro W.LsVn Iftt. <br /> 7.Transporter 2 Company Name U,S.EPA ID Number <br /> 8.Designated Fa Nam and Site Address U.S.EPA ID Number <br /> EAXERS11-111;TRANSFER INC. At:�rAo2594%+ <br /> 16XI1=.i3R13AI13AGE iii <br /> II»t� FrF.l.R.,Gt� � �9 Efj)/IRONMENTAL,. <br /> 7 <br /> FadWs Pune; <br /> 9a. 9ti:U:S:DOT ..-. (tnckrdktg Proper Stiippahg Name.Hazard Class ID fJnbaher 10.Containers.. 11:Tglal 12 Unit 13.Waste Codes <br /> HM- and Packing Group(if any)) No. Type Quantity WLNol. <br /> .1 1 .'•ir.:.N P"IR4t4, sftf?C?�t:i L"o'f'a'n`L' ,uCY c iir4'� Cf`rt`Fk.1!�'Ta} i)_I � w <br /> lu <br /> 2 � <br /> E <br /> 3. € <br /> E <br /> i 1 <br /> 4. <br /> 14.Special Handling Instructions andAddittonal <br /> pinformation�y /�j �p g /� .�+ ! <br /> VkG#1'•1 t31 ;�� ET f6 1 -(/) °..V 4" t wi'e«r4reF? f <br /> VVEAR <br /> 15. GENERATOR'SIOFFEROWS CERTIRCATtON.i hereby declare that the cent of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> markerd and labeled/placarded,and are In as respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I ce*that the contents of Cgs consignment conform to the temns of the attached EPA Acknowledgment of Consent <br /> t certify that the waste minimization statement identified in 40 CFR 262,27(a)(If I am a large quentily generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's(OfferoesPnkh y*.Name r S Month Day Year <br /> r ) r <br /> -j 16.International Shipmen <br /> fmportto U.S. from U.S. Pont of entry/exit <br /> M Transporter signature(for exports only): Date leaving U.S.: <br /> UW 17.TransporterAdmowledgment of Receipt of Materials <br /> Ij Transporter 1 PrIntedlTypedNameS' ` Mann Day Year <br /> O �p� . a s: <br /> o � <br /> QTransporter 2 Pruttedit'yped N ,' Signal- �. Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indicdon Space ❑ Quantity ❑Type ❑Residue ❑Partici Rejection ❑Full Rejection <br /> Manilbat Reference Number. <br /> 18b.Alternate Facility,(or Generator) U.S.EPA ID Manlier <br /> U <br /> ria FadWs Phone: <br /> 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> S2 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) . <br /> 1 h 2 3. 4. <br /> 20.Designaled Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item lea <br /> Pdnted(typed Nam i Signature �s j Month Day ear <br /> EPA Form 8700-22 ftv.3=05) Previous editions are obsolete. �<-''" TRANSPORTER'S COPY <br />