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4f <br />Please orint or tvoe. (Form deslanp.d fnr iuzp rm olffi, lvxnitrhl h,� ... ;#., % 71*51.5,72 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />fA'aa I fit fiftv�' h&i ;40ii:*p Pin wv'� Ar 1"d Ynh 1C4 -q1 i,h'e jteS's i", 41ifi, , " <br />pmg <br />...... <br />r'JL I 'uv. VWM0 No. Zu0U-j!j <br />UNIFORM HAZARDOUS 1. GenembrID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest kIT9 Number <br />29 <br />WASTE MANIFEST C A 0 9 19 .3 (:t 0 54 4 (800) 4 Jc -3 3"7 j S <br />0 0 6 3 7 FLE. <br />J-51 <br />5. Generators Name and Mailing <br />9- t"'t1tress Generators Site Address "(i differerd than mailing address) <br />Generators Phone: <br />67r—ansporter 1 Company Name <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S, EPA 10 Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />(1pao <br />iOW"t Gtnf�iwi'ij '5 13 4 V-' 4 <br />Fact' l es Phone: - T:) <br />ga. <br />9b. U.S. DOT Description (Including Proper Shipping Name. Hazard Clan, 10 Number, <br />10. Containers <br />11 <br />12 Unit <br />HM <br />and Packing Group (if any)) <br />-Total <br />Quantity <br />WtjV0l. <br />13. Waste Codes <br />No. <br />Type—] <br />i. Nt0N !'113011f"X& <br />'14, <br />3 <br />0 <br />,V'AVEP, 1i11%1W-,1,F <br />LU <br />Z <br />2. <br />ul <br />3, <br />4. <br />_1nstWDns <br />114. Special Handling and Additional Informag7n <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 ERAAcknowledgme I Consent. <br />I certify that the waste minimization statement identified In 40 CFR 262.27(a) (if I am a large qua 1b) (If I a small quantity generator) is true. <br />Ge F s/Offerors Print Name n 9155111 95—Y --- Ye—a r- <br />7 am 6 n A,' & �. <br />=j <br />1.— <br />16. International Shipments- * — <br />1:1 Import to U.S. ❑ Export from U.S. Port .fentry/exit: <br />M <br />Transputer 'qnature for exports onl; Date feaving U.S.: <br />Ll <br />ff: <br />17 TranspoderAz*noW,-dgwent ofRowiptofMatedals <br />L2 <br />0 <br />Transporter 1 Fnn_tWffyped Name SignatureMonth Year <br />CL <br />Y <br />Z <br />< <br />Transporter 2 Printedirlyped Name -Signature Month Day Year <br />is. Discrepancy <br />18a. Discrepancy Indication Space 0 Quantity [:]Type El Residue Partial R.Jecb.n D Full Rejiectlon <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S, EPA ID Number <br />U< <br />0 <br />uj <br />Facililys Phone: <br />1 <br />Ise. Signature ofAftemate Facility (or Generator) Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />,11. 0.1141 <br />1 2. <br />T_ <br />4. <br />20, Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted In Item l8a <br />Printecl/Typedl Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />fA'aa I fit fiftv�' h&i ;40ii:*p Pin wv'� Ar 1"d Ynh 1C4 -q1 i,h'e jteS's i", 41ifi, , " <br />pmg <br />