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Fiease print or type. (Form designed for use on elite 12- itch ; ewli er. „ ?, Form Approved, OMB No. 2050 0039
<br /> ' UNIFORM I AZARbOUS i , Ganaralor ID Number � s 2 Page.1'of , Emery ricyResponse Phone.: 4, Man fest Tracking Numher
<br /> WASTE MANIFEST . !. C li t_ CJ f1O,,a3, 3 F� FF. 1tCt( } Qr; , t} it�E4% A p i� K
<br /> 5pppppppi�. eife, l rapNameandMail(ngAddress - &� tJ
<br /> li f`l/ 'fldU(if;if><(i - t f :f f)()4i Y GenerataYsSlteAddress (if different than mating address)
<br /> F0 BOX 6207
<br /> ( ,,` p" j # IF IF I
<br /> GenaralorsPhone: iii i' III, I FFSIC f;j5•I•ON .. C)Ar;. ': .. ..{ar�'s � ;j, •"i
<br /> 64 Transpoder 1 'Company Name
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<br /> 7, Transporter 2 Company Name U.S. EPA ID Number
<br /> 8. Designated$acfifty Name and SIIeAddress r
<br /> U.S. EPA ID Number
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<br /> FadlilysPhone '(3 t}dr7 frabCl 'i C1 !) ( { fl I I
<br /> 0 F) 3
<br /> IF
<br /> 9a. gb. U.S. DOT Dascdptlon (Including Proper Shipping Name, Hazard ClaF .ss, ID Number, :, 10. Containers „ ; , , dirTptah , . t2 ?Unh•
<br /> HM andPatkingGroup (ifany)) t3rWasteCodes
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<br /> No Type Quantity ,W[Nol,
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<br /> iq: Speci�l;Hertdling inatructlons and'Addiltdnafinformation z, '
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<br /> 150 , GI:NERA7OR'¢/OFFEROR'$'C FF.RTIpIGATION: 1 hereby declprg4hat the'contente•af this ybnstgrime0(@re fylly acid accurately.described above by the groper shipping name, : are;clessl8ed, papkeged,
<br /> marked'and Iabeledfplacaided, end are fn au respect's in proper bond tion for trarispOrl acPgr'ding fo�appllg bt@ Irjlerttalbi(al and national goyemmental regulations:IPexportshipmeht and I am.the,P,dinary
<br /> Exporiet I certify ihafihe contents of This eonsfgnmen{cantorm to thelerms of Ihe.aftpWdd i PA'Acktwwtedgment of CUnsen(;
<br /> Lcedi(y that the wastA'minlm4zallon statement identified in 40 CFR 262:27(a) (If I am a fafge q . anlltygeri$ratgr) 0'7'(b)'(If i am a small quanUfyger�Qrator) Is tree. ;:
<br /> Gen eratof+alOHeroftsPrinted/iyped'NameFF V hI
<br /> Signature, . . . FF
<br /> Month Day IF
<br /> Year
<br /> till
<br /> IniernatloIV
<br /> nal Shipments r---I e �_.
<br /> Import to U,S. t_1 'Export from U.S. Port of enlrylexiL
<br /> Transporter algnetura (for exports only):
<br /> t Data leaving U,S i
<br /> 'w 17, TranapoderAcknowtedgmentifReceiptofMaterials • ,
<br /> Fill
<br /> �. Transpoder`l Printed/Type ame . '
<br /> 0 VA . • Slgnalure
<br /> a �, e f y rJrr� ' Mort h DaYr: 6a(
<br /> rndJiypedNam rte_ •. x . „ ,. . Y 3; :d•1r k� sf
<br /> dzt Transporler2Pdnte S n t rem �'r Lf 109
<br /> �'Y
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<br /> Month Day Year
<br /> 18rDlsaepancy1 jot
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<br /> VOW
<br /> 18a: Discrepancy Indication spaceIV
<br /> O Quantity T pe
<br /> y ❑ Residue 0 ParUal Rejection , Full'RejecUon
<br /> Manifest Reference Number.
<br /> 18b. Aflame la�t+ac1)(y'(or Generator) U.S. EPA ID N mlrerFF
<br /> V
<br /> uQ. Fadtity's Phone;.
<br /> W 18c;&Ignalure ofARemale Facility (orGeneralor)
<br /> Q ( ' Month Day Year
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<br /> 19. Hazardous Wasfe Report.Managemenl Method Codes (La:; code§ for hazardous waste treatment, disposal,-and reaydGrg sys(ems) I VIVO
<br /> 1' 2• 3:
<br /> 1. 4,
<br /> �0.: Dbsjggbled Facility Owner or 0 grator, Certification of recelplof hazardous jnalefiais wvered by the manifest except as acted in Item 18a /
<br /> Pdnted6Typed Name FF V. Signature FF
<br /> a 7. podj210' .. ' .. r g toor paimpiwo ,Iii Doth Day poo"VoiYear
<br /> EPA Form 8700-22 (Rev. 3 05jr Previous editions aro oft
<br /> soleta. y< TRANS Wf7 ;
<br /> RI FR.:� COPY
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