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713y7-6-757 007275722 $K$ <br /> Please print or type. Form Approved.OMB No.2050.0038 <br /> UNIFORM HAZARDOUS 1.Generator ID Number i ,s 2.P e of 3.�mefg 'RQ_spops_e PPPjWn 4.Mano sl Tracking Number �� <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generators Site Address(if ddfemnt than mailing address) <br /> s <br /> A <br /> Generators Phone: - <br /> 6.Trposppcterjf:ompTSTEMq;y_ - U.S.EPA ID Number <br /> 7 Tra_nspo_rlerr2 Company Name U.S.EPA ID Number __ 17,_ <br /> 7. <br /> 8.Designated Facility Nameand Site Address AN HAP'ki-pr. c is Trx.;:-. U.S.EPA 1O Number <br /> QN <br /> Facili 's Phone: <br /> ga 96.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1. w rj ^R4 IFZF DOUe WpQrF0( -,c "M <br /> ''� <br /> 3. <br /> 4. <br /> 14 Special Handling Instructions and Additional Information r y}:C.1 <br /> t_, <br /> , eT rl <br /> T' Ak42 69 � <br /> -7. z <br /> 15. GENERATOR'SIOFFEROICS'CERTIFICATION:thereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, r <br /> marked and labeleN 'and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.If export shipmentand I am the Primary <br /> Exporter,I certify th tmritents 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 25227(a)('d f am a large quantity generator)or(b)(if[am a small quantity generator)is hue. <br /> rors Nnterlry d N e Sig "Month Day Year <br /> 16.International Shipments <br /> z ❑Import to U.S. ❑Export from U.S. Pod of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> X 17.Transporter Acknowledgment of Receipt of Materials <br /> 1 Pdnted7Typed N ,/�/) gnature ' Month Day Year <br /> -T7C(-C�,/ / <br /> z er 2 Pdnted7Typ acme gnature J Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space <br /> Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone, <br /> w 18c.Signature ofAltemate Facility(orGenerator) Month Day Year <br /> a f <br /> z ' <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codesfor hazardous waste trea8nent,disposal,and recycling systems) <br /> uj p 1. 2. 3. 4 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazallm materials covered by the manifest ecce as noted in 1&8a <br /> PrintedlTyped Name Signature Mon Day Y r <br /> EPA Form 8700-22(Rev 12.171 Previ0L,5edrbons are obsoete�rry, DES ATE A I�ITY TO EPA's e-MANIFEST SYSTEM <br />