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0 <br /> Please pont or type. F Form App—li'd OrAB NO.20YrIK <br /> } UNIFO 1°rtn designed 1°r use on Brite f12pltchl typewriter) ��C <br /> Pleas I WASiM NAZARDOUS I G—W,ID Number Page I s Einer Ismso Pnru�e en lest r.cYlnp a7 <br /> E MANIFEST gen<r Nes i ,1 V <br /> 1 5 GFneratnrs Name and Mailing'no—s f wralora Sun Aoi +s ainoronl Nen--v <br /> edCraKl y <br /> I Generator's Phone <br /> F mnsporter 1 C°mn.rny N,inie U.s.EPA ID Number <br /> ].Transporter 2 Cmpany Name U EPA ID Number <br /> 8.Designated Facility Name end Ste Adtlmss U S EPA ID Numbe' <br /> Facibry'S Phone. <br /> ga. eb.U.S.DOT Desatption finrJudirg Proper Shipping Na...Hazard Class.ID Number, 10.Containers 11.Total 12 Un,l ,3 Waste Codas <br /> HM and Packing Gmup rd any)) No. Type Ouanlity W7 Not <br /> f <br /> O <br /> Q <br /> C W <br /> a w <br /> z <br /> u <br /> Ic <br /> ( E <br /> II I 14.Special Handling Instructions and Additional Information <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION:I herebydeclare that the contents of this consignment are full and accuralel described above b the proper shipping name,and are Gasified,packaged, <br /> !' marked and labeledrplararded,and are in all respects in proper condition for transport accordingtoapplicable international andnationalgovernmental 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 /> rr 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 true. Monti Day Year <br /> Generators/Offerors Printed/Typed Name Signature <br /> i <br /> —1 16.International Shipments <br /> ZImport to U.S. ❑Export from U.S. Port of entry/exit! <br /> Transporter signature(for exports only): Date leaving U.S.' <br /> . W 17.Transporter Acknowledgment of Receipt of Materials Day Year <br /> � Name Transporter 1 Prinled/Typed NMonth <br /> � Signature <br /> CL <br /> Q Aansporter2Printed/TypedName g <br /> Si nature <br /> Month Day Year <br /> I t <br /> I18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Full Rejection <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection I <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ri Facility's Phone. <br /> H18c.Signature o/Altemate Facility(or Generator) Month Day Year <br /> D <br /> 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. <br /> .q N. 2. 3. 4. <br /> I20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedi of Name <br /> Sgnat"e Month Day Year 1 <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete I I <br /> GENERATOR'S INITIAL COPY <br />