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Phase pnnl or type.(Form designed for use m elite 112•pach) ler l <br /> I UNIFORM IWAROOUB I Gnlantw tD Numte, )PmJ.l w 1 t --:r - Fam to-.•. <br /> WAST#MANIFEST y',� crew" <br /> _ ,�J K <br /> 5 Generab/s Name arta.......a AUdress -77- 0166454' <br /> - .i yyr.,ryYrq seGey, . n/L�v <br /> 1W <br /> VIFEST <br /> ,38nera11r F6Ma <br /> 6-T.anaporter 1 Company Name - <br /> U 4 A l Nurrtr ss <br /> 7.Transporter 2 Company Name .!s FM ID Honest <br /> 8 Des,gnaled Fapeay Name and Site AddRs, U S EPA 10 N-bar <br /> I N% <br /> Faciery's Plbne <br /> ga 9a.U S.DOT Descnphon ondudna Proper Shmpinq Name,Hazard Class ID Number 10 Contemers 11.Total 12 Una 1a Was-C,,dWA <br /> HM and Packing Group(dany)l No Type Open1'ty, <br /> O c <br /> f.7 <br /> I <br /> 1 <br /> r <br /> ' 14.Special Handling Instructions and Additional Information. I <br /> O <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name.and are OIaS5dled,pacsagec <br /> 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 Me Pmmary <br /> Exporter.1 ce"that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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. <br /> Generafors.rOfleror's Printed/Typed Name Signature - --. <br /> -sq' <br /> J 16.International Shipments <br /> I ❑Import to U.S. ❑Export from U.S. Port of entrylexit: - <br /> z Transporter signature(for exports only): Dale leaving U.S.. <br /> LL 17.TransporlerAcknowledgmenl of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Monti- Day Vea' <br /> a AC <br /> 1 Z Transporter 2 Printed/Typed Name Signature Month Day Yeat <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ---- ❑Quantity ❑Type ❑Residue ❑Partial Rejection Full 12e'.=.-car. <br /> Manifest Reference Number. <br /> F 18b Alternate Facility(or Generator) U.S EPA ID Number <br /> J <br /> V <br /> fi Facility's Phone: <br /> AM <br /> tuL 18c.Signature ofAltemate Facility(or Generator) Month Day' Year <br /> a <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> r <br /> 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br /> PnntedrTyped Name Sinnature Mnnth Dav 'fear <br /> y <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> c� <br />