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c m Form Approve d.OMB No.2050-0039 <br /> type.(Form designed for use on elite(12-pitch)typewriter.) 4.Manifest Trackrn Number <br /> 1.Generator ID b r_ 2 Paq 1 of 3.Emetg noy ResRonse P, yore: r F 9 ,t <br /> ORM HAZARDOUS Tt i� r1 f € �)aT � '. <br /> b5 � JJK <br /> N WASTE MANIFEST <br /> m 5.Generators Name and Mailing Address Generator s Site Address(if different than mailing address) <br /> `m tP lffi? E:. 6Bt'R?t4lCa'e.51 <br /> S3.i t,.at�l,r:y«xrl r46,P }¢g¢rrri7 t,t p <br /> .f:1.t4,t ft''3ct k:tP f 7 �^ tea-o(ictrirl,t na 5?1!2 <br /> rti31'.tEui•ji e,e.r. :1:a� 1,.7.�^L' (j'!$ 3 -'q.?rv� <br /> Generator's Phone: U.S.EPA ID Number <br /> 6.Trans (ter 1 ComQany Na§m' CA!r]i;.t{ <br /> r'. . 2t�;r <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 1.l: lzrwf <br /> st <br /> Facilitys Phone:7-77-7777-77 ::'•+qts-E;C t3ti4 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> Quantity Wt./Vol. <br /> and Packing Group(if any)) No. Type <br /> 1. <br /> OF "l'#tt�f+bq;!'tf•'3i�l �+?a:.l:tlt��5�v'(i'.ilttllf"I(g.t>•,�-:;fiff})�' <br /> oo Yi! <br /> Q F <br /> W 2 <br /> UJ <br /> 3. Xdh t e aPProprraa perm 'Po _..__....�. �_ n...,,_m. _,. .�....._.. <br /> receive your waste, and has received the -E <br /> 4 waste,Our Number is <br /> 14.Special Handling Instructions and Additional Information y fir•i„ � fir"< 3 <br /> Jdye_k_-iFr6PP.an--> <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,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 /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minifization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Signature Month Da Year <br /> Generator'si0ff s• ntedlT Nowa- �- <br /> 16.International$hIpmentp Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): __Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials Month DS Year <br /> �T�4n7yed Na ( Signat re f � '� &d " � 1�`2 � �a° ..J Month Day t Year <br /> Qped Name Signature p <br /> fi <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 0 Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> a <br /> uQ. Facility's Phone: Month Day Year <br /> W 18c.Signature of Altemate Facility(or Generator) <br /> 4 <br /> 0 19.Hazardous Waste Report Management MethodCodes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 g 2. <br /> 3. 4. <br /> 20.Designated Facility J(Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item I Be Month Day Year <br /> Printedrryped Name I Signature !!I ..-_ I t P <br /> t F 0 A--} -, I& ��FR. C-1 c_ ( i t 4 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. - DESIGNATED FACILITY TO GENERATOR <br />