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Please print or pe:(Form designed for use on elite12- Itch ewriterr) Form Approved...OMp3:No.o
<br /> UNIFORM HAZARDOUS'4,Generator ID Number 2,Page 1 of 3.Emergency Response Phone. 4.Manifest Tracking Number
<br /> WASTE MANIFEST t;:,4t Ct00 r1 ;8 f iiYU 3 i!•.;1=1•. Q 13 4 3 5 3 0.9 Nt1J" •
<br /> S:Generator'a Name and Malang Address Generatoft Sllq Agdress(if dJfierent than malling address),,
<br /> !Li110 tl'WA',
<br /> PA PDX t 9.
<br /> Generators Phone: II' q'A irn
<br /> 6.Trenspo er 1.Coriipeny.Naitder:!;:'n r..• ::::::.;-z•:: ;::•ie•.t r U.S;EPA ID Numb'er'-
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<br /> 7.Transporter 2.Company Name U.S,FPA ID'Number
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<br /> gest ated,Fgc Address - :�••�„ i+ U.S.EPA
<br /> •: Afly ltt°Wi,�bF) Name and Site ID Number. .... . , . ... .�,�C„lG'^'•.an:,�.a
<br /> ' 'i6�•�•gRtJNpIiIGP l:tJ ., ,. ., ,..;,,;.•:,�.• ,
<br /> Fadli sPhoneyt' f,:iWA:"Lr,....,�,: ...
<br /> 8a, 9b:1).S,DDi fde's'aiptlon,(Indudng Proper Shipp(ng Name,Hazard.Glass,I�Nujnber. ;<10.Conlairiers,..,..
<br /> ' m.Total .12,.Unit...
<br /> HM and Packing.Group:.(If any)):_.., .. ,:. .. Wasto Codes
<br /> No:� Type uanilly WLIVOL 13
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<br /> 94.Special dandling Instructions and Additional information �.
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<br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this conslilpTagt are fully and accurately described above by the proper shipping name,ard are VV classified,packaged,
<br /> marked'and labeled/piacarded;8nd a46 all rospec(s'fn proper condttion for transport a000rding to applicable International and national governmental regulations.If exportahipment and I am the Primary
<br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent:
<br /> 1 certify Ihailhewaste minimizatlon statement identified in 40 CFR 21i2,27(a)(if 1 am a large quantity generator)or(b)(ifl am a small quantity generator)Is true.
<br /> Generatoest09erves Pdnledfiyped Name -Signature Month Day Year
<br /> -4 16.International Shipments
<br /> F" D impod to U.S. D Export from U.S. Port of entry/exit: '
<br /> Transporter elgneturo(for exports only): Date leaving U.S.:
<br /> ..t<7,TransportdrAckno%109ment of Receipt of Transporter 1 PdnledtTypad Name Signature Month Day .: Year
<br /> Transporter 2PdntedlTyped time Signature 'Month . .Day . Year
<br /> F
<br /> 18a.Discrepancy Indicatton Space O Quantity �7ype C!Residue D Partial ReJec6on ❑Full Refection
<br /> Manifest Reference Number,
<br /> 18b.ARemate Facllity,(or Generator) U.S.EPA ID Number
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<br /> Facility's Phone:
<br /> Lo 18c.SignatureofAltematsFacility(orGenerator) Month Day Year
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<br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for,hazardous waste Ueatment,disposal,and recycling systems)
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<br /> 20,Designated Facility Ownee or Operator:Cortif:callon of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Pr nled/ryped Name, t' Signature i Month ay ear•_.
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<br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. ” ` " ! TRANSPORTER'S COPY
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