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Please print or type.(Form designed for use on elile(12-pitch)typewriter.) UNIFORM HAZARDOUS 1 Generator ID Number page 1 0l ].Emergency Re F.-Approved.OMB No.Zn5n-UOl9 WASTE MANIFEST sppnsn Pnone a.Mannn`p^t�7�cMlna Bumper 5.GenemloY9 Name antl Mailing Address GBnemloYs Site Address lit dleerenl than mai EresyI r �� Generator s Phone' 6 Transporter 1 Company Name US EPA ID Number I 7 Tl—inner 2 Company Na,- U S.EPA ID Number 'N/FEST 8 Designated Facility Name and Site Address U.S.EPA to Numbei FaOdy's Phone' Pa. 915 U.S DOT Des—, ,',,i,no Pr, SI i - ,-.,ori. 10.Containers , ..asre Godes HAA and Packing Group i' '•. No. Type ern - I rY 6 z w I 14.Special Handlin_q Instructions and Additional Information r 15 GENERATOR'S/OFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified.packaged. 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. _ 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 a small quantity generator)is We. Generalor's/Off'eror's Printed/Typed Name Signature Month Day Year - J 16.International Shipments ❑ zImport to U.S. ❑Export from U.S. Port of entrylexiC. Transprte or signature(for exports only): Date leaving U.S.. Transporter AcknowledgmentofReceipt ofMaterials O Transporter 1 PrintedrTyped Name E r r Signature P.1onl'n Day Yea! a Q Transporter2 Printed/Typed Name � Signature Month Day Year Z, f 18.Discrepancy 18a.Discrepancy Indication Space Tv:) ❑Residue ❑Partial Rejection ❑Full Rejection 186.Alternate Facility(or Generator) Manifest Reference Number. U.S.EPA ID Number U � - IQ Facility's Phone: w 18c Signature Of Alternate Facility(or Generator) Month Day Year Q N19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) T �I R TF 1 2 3 4. r 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba _ Phnted�Typed Name Signature Month pay Year qf�f EPA Form 8700-22(Rev 3-05) Previous editions are obsolete. Cast GENERATOR'S INITIAL COPY a' r: