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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest TTrr°ac/k�n er <br /> WASTE MANIFEST CACQC�{6Z-14 $�I '?- `� ® v'* 4 71 G B F <br /> 5.Generator s Nam d(1Lg�10yin %o Com. � Generator' Sits, a Addres ifferent than r�ilin�ad`reti2D <br /> �+�-�J�% .26`0 cyle <br /> G Ji2•'L�M•�L.r�1 G�/t �rC. � <br /> 4 C410. q5-3bo-f <br /> Ge =S . <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> IA2-r- ?y0 EL <br /> 7.Transporter 2 Company Name U.S.EPA ID Number , <br /> sen-l-1 C' Pi(t: GG "a�� CSS lw�✓'C/y).s .SC00 l lU l!2 <br /> 11 <br /> 8.Desi n`t lity Name and Site Address U.S.EPA ID Number <br /> 2a; f f�-tl�4lA D� <br /> 1P91. 0 <br /> Facility's P ��� v ' 2-1466 �� -73 19 <br /> 9a. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. 0116V4AzceA <br /> (PIMIC,Eft"T-1 0+L-) <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> TZ <br /> Q.O GI b vvlls <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 al 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 EPA Acknowledgment 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 sm ntity generator)is true. <br /> Gen rato IOfferor's Printed/Typed Nam Signature Month Day Year <br /> 16. nterna4onal Shipmen <br /> ❑Import to U.S. Export from U.S. Port afentry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> 1% 17.Transporter Acknowledgment of Receipt of Materials <br /> w Signet Month Day Year <br /> Tranl..,,/ow 115 104� 00W <br /> Qrter 1P rintedfryped Name e <br /> IL <br /> z Transporter PrintedlType Name Signat /`- Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> rai Facility's Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials co red he manifest except as noted in m 18a Month Day Year <br /> Printed ped Name Signature <br /> EPA Form 8700-22(Rev -1 Previous editions a bsolete. D GNATEVFA ®EPA's t?-{MANIFEST SAY S T7, <br />