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L 1' -0 0) N <br /> Cl) Pie nod for use on elke 12- itch O N N <br /> O eBe Print Or yps r OUS ,Gnnera 00 ID Nu p } ew'dter.} <br /> mhnr <br /> Rp O <br /> Z UNIFpRM, sr 2.Page I of N N <br /> wABTF#11 „;M.elhn,l A,fdr .•. 7 Emrr9enay p.::rrmse Phone Fpmlp O <br /> 4.plant Aprovetl OMB No.2b5U-GF13g O O <br /> D 5 Gene, rackFng Numlxr [n <br /> Genaral0ts Srle Arid 111 O�' CD <br /> D rays(rt dl man markinJ <br /> ress1 g add <br /> z � <br /> ,„a i�nn,pnrny N,nur �. <br /> m a"'``r v D <br /> (/) r:mp.rn(-NnR». N G <br /> U.S.EPA ID Nurnker <br /> Q <br /> grA FadSil <br /> Nly Namre and leAddress O <br /> U,S.EPA ID rrumher <br /> U1 <br /> U-S.EPA IG Numher <br /> Facmry',Fhomar -r 9r ai <br /> r-F <br /> 9a 9b.U.S.DOT Oescdption(including proper Shi <br /> HM and Packing Group(if any)) pPin9 Name.Hazard <br /> Class,ID NumGer, <br /> 10.C012rnars IL <br /> � <br /> p Na. 11.TalaE tZ.Unn (D <br /> rk Type Quantity iryt.Nal. "'7l", .^ <br /> LU rr <br /> Z O <br /> 00 <br /> F� <br /> v <br /> 1 O <br /> N <br /> V <br /> (r1 <br /> 7Z <br /> O <br /> LA <br /> IS <br /> 14.Special Handling Instructions and Additional Information fD <br /> G <br /> (D <br /> Q <br /> fr <br /> 15. GENERATOR'SIOFFEll OR'S CERTIFICATION:I herehy declare that the contenls of this consignment are full S <br /> O <br /> marked and labeledlpiacarded,and are in all res respects inproper <br /> Expo ter,I certi g condition for transport according W applicable r lemati nal and nationalescrha emVA Y 110 Proper shipping name,and are dassmed,packaged, p� <br /> fy thal the contenls Vc <br /> of this Consignment conform to the terms of the attached EPAAcknowledgmnle of Consent, g <br /> I certify That the waste minimization statement identified in 40 CFR Z2.27(a)(if I e a a c a regulations.ff export shipment and I am the Primary <br /> Generator's1 Q <br /> OfFero s Phnted)Typed Name r9 quantity generator)or(bl(i!f am a small uan (D <br /> 9 WY 9enereWrJ is we. � <br /> Signature <br /> J 76.IntemMonth Day Year <br /> International 7 <br /> F- <br /> z ❑Import to Us, I 1`5 r-r <br /> Transporter signature(for exports oniy): ❑Export from U S. Port ofentrylexiT N <br /> 17.TransporterAcknowledgmenl of Receipt of Materials Date leaving U.S.: t7 <br /> Q <br /> O Transporter 1 Pnnted7yped Name O <br /> Signature <br /> Q co Month pay Year <br /> ZTransporter 2 PrntedlTyped Name <br /> � Signature <br /> I Month <br /> 78.Discrepancy Day Year <br /> 18a,Discrepancy Indication space <br /> ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Reiection ❑Ful!Rejection <br /> 18b.Alternate Faalily(or Generator} Manifest Reference Numhec <br /> J <br /> U U.S.EPA ID Numher <br /> ri FaerliVs Phone <br /> w 1&-Signature 01Altemate Facility(or Generalor) <br /> a <br /> Z Month Day Year O <br /> ro ig.Hazardous was Report Management Method Codes(i.e.,codes for hazardous wasle treatment,disposal.and recycling systems) (Q l7 <br /> LU 7 O <br /> O 2. O Q <br /> 3. 4 <br /> 20.Designated Facility Owner o <br /> PrintedlTyped Name except as noted in Item 1 Be Operal0r.Codification of receipt of hazardous matenets covered by the manifest et ed <br /> Slgnalure � <br /> Month Day year O <br /> EPA Form 8700-22(Rev.""PI Previous editions are Obsolete,1 <br /> rn <br /> CD GENERATOR'S INITIAL COPY <br /> O <br /> w <br /> O <br />