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.5 <br /> Form Approved.OMB No.2050-0039 <br /> mor type.(Form designed for use on elite(12 pitch)typewriter.) f� f %` ,�!,' :. fr %r <br /> 1.Generator ID u.ber 2 Page 7 of 3 Emergen 13e pp se e- 4.Manif�eyst Tracking Number <br /> UNIFORM H.AZAR�OUS lu t- Liu �a I��: cs C. d. :k �t _f�t1 fO i � �7^634 JJK <br /> 3534- <br /> -WASTE MANIFEST <br /> 5.Gen&ratP�Ffd�a!2@,Irnd �illg9�f � .�r s �x f� f "J"� t� P ) <br /> Generator s Site Address(ff diBerent than mailing address) <br /> ...o.�+^ sax1.'�E f fslt'Fr rlteF In <br /> J <br /> ['r, t=aaF42k1 t`� (srt . 1 ,, (, rt rf 1L i'. ., (.rP` �. <br /> =,Crrie^ur�4=ia�x521� - <br /> La SS211 <br /> 241]l49,lib.) kG <br /> r6an <br /> ator's Phone: U.S.EPA ID Number <br /> sporter 1 Company Name <br /> U DNumS EPA l bersporter 2 Company Name <br /> ,Irf� �'' c` f U.S.EPA ID Number <br /> i�i,t10, cillity Name and Site Address <br /> 1000f;.4'i3.4e+`4 <br /> 2040 4 Ill fi I <br /> 10�t3624 <br /> r9a. <br /> ty's Phone: <br /> }40-27-4-25 5 <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Gontainers Qu Total 12.Unit 13.Waste Codes <br /> and Packing Group(if any)) No. TypeQuantity Wt.Nol. <br /> r r <br /> 1. ($idr rEr +:$:`idEeSi;avrl ?�zkF ifEil(i3fjy'�dg?„�S'.aArli)4).=�1� sr-t 1.tt�'T <br /> o <br /> LU <br /> 3. <br /> _. .. .. <br /> 4. <br /> I <br /> 14.Special Handling Instructions and Additional Information r <br /> r,ry-- YCi .7IQ4-74z f � .. :.. „ .. <br /> .pry_ �a <br /> 45 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fulty 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.Itexport shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste mininivztion 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 ,ontay <br /> Generator'slOfferor's:PInted(Typed Name. ,.. .. <br /> . <br /> r —j 16.Internal I Shipments ❑Import to U.S. ❑Export from l Pod of entryleAt <br /> a° j— .r <br /> OE' Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Signatu Month Day Year <br /> r' Transporter 1 .dntediTyped;Name. , A { fir <br /> a Month Day Year <br /> Z Transpodeel PPhnt/edlTyypped Name �.�r f /� / Si nature <br /> F— / f L..+7r.-�'s"I.•A'rfI r7 f`t! f` /-/ ert% <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ElQuantity ElType ElResidue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate.Facility-(or-Generator)"'- -z <br /> Zi <br /> U <br /> -4- Facility's Phone: Month Day Year <br /> OL 18c.Signature of Attemate Facility(or Generator) <br /> Q <br /> Z <br /> S219.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1 2. 3 <br /> C3 . 4. <br /> ? ;' <br /> 20 Designated Facility Ownet of Operetdr Certcation of receipt of hazardous materials covered by the manifest except as noted in Item 18a Montp Days Year <br /> Signature 4 n <br /> 1'nntgd/Typed Name s ;� " f r, ` t ;• r ', v .- <br /> ' „ ,ef•. - P z1•• o? t;�` rd! _: f c:._, .✓£ s _ r. .r` <br /> ” <EPAForm'8700-22(Rev.3 05) Prev'i'ous editions are obsolete. tt ': - ;DESIGNATED FACILITY TO GENERATOR <br />