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'"N i_•j ..% Form Approved.OMB No.2050-0039
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<br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Ira��n¢g Number
<br /> 4R1+11 HAZARDOUS 5 x to 476-1?F.e-0 b w� { `�"
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<br /> WASTE MANIFEST s
<br /> 5.GAnerator's Name and Ma'linrq Addrgss, Generator's Site Address(d different than mailing address)
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<br /> Generator's Phone: U.S.EPA ID Number
<br /> 6.Transporter 1 Company Name
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<br /> 7.Transporter 2 Compan Name _ ,
<br /> U.S.EPA ID Number
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<br /> B. ,�r„�a d Fa�cih Name and Site Address e° a q c"d U.S.EPA ID Number
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<br /> FacilitysPhone;
<br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes
<br /> 9a. No. Type Quantity Wt.N01.
<br /> HM and Packing Group(rf any))
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<br /> 14.special Handling Instructions and Addibonal Information r 4 �
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<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 labeledlplacarded,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 minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quant)ty generator)is true.
<br /> Signature f : .d Month Day Year
<br /> GeneratoeslQfferols PrintedlTyped Name
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<br /> F 16.International Sh)ments ❑Ex ort from U.S. J tort of entry/exit.
<br /> ❑import to U.S. p �.r
<br /> K Transporter signature(for exports only): Date leaving U.S.:
<br /> W 17.1figsporter Acknowledgment of Receipt of Materials Pr
<br /> Signatu Month Day Year
<br /> Transpo�rf�en•1 Printed/Typed Name, y ! �
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<br /> J04',r p., ('t'"6 k_, Month hDay Year
<br /> Z Transporter 2 Printed/Typed Name Signature n —?S t ,
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<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space El Quantity ❑Type �/10 Residue ❑Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number.
<br /> U.S.EPA ID Number
<br /> 18b.Alternate Facility(or Generator)
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<br /> `Facility'SPhone^ `""` µ w Month Day Year
<br /> W 1 BC.Signature of Alternate Facility(or Generator)
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<br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
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<br /> 29.Designated Facility OwnerAr Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a J
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<br /> Day,.._ Year
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<br /> PriptQdlTyped Name / f E r v , �+ i' j j;r f
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<br /> ILITY TO GENERATOR
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. .` l DESIGNATED FAC
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