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<br /> Please print or pe:(Form designed for use on elite 12-pitch typewriter,) �. .
<br /> Form Approved.0 0...20
<br /> UNIFORM HAZARDOUS 11.Generator ID Number 2,Page lot '3,Emergency Response Moro anifest Tracking Number
<br /> =WASTH•MANIFEST 4.'.L�,h>w"•8�5�t; i . �t?1:g.1;.mi.{..K'St'irr�..
<br /> 5.Generators Name-Abd Melling Addreas 'Gener&6 Sltom tess(if different thanmalfng address)
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<br /> Generator's Phone: ' ';'1 .Z1 �' '`t
<br /> B.Trfg3Aot�dr W0qqn NaMe-'.*% 'f : ' :,r• , ,. , U'.S':EP�A�ID:Number,'±' .armp
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<br /> 7.Tmnspoiter 2 Company Name U.S.EPA ID Number
<br /> U.S.EPA ID Number
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<br /> ga ;tib.U:S:DOTDesafptbir Qnduding PropeaShipping NaMe'Hpzert Class,l ,Number,;,..:._, 3,Waste Codes
<br /> HM 'and paddng Group(if any))
<br /> 11 Total . 12.Unit 1
<br /> No, Type QuQntity wtivol..
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<br /> 14.Special Handling instructions and Additional tnforma n . . // ;J _) c�
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<br /> 16. GENERATOR'SIOFFEROR'S CERTIFICATION:;I hereby declari that the contents of this consignment ire fully and accurately desbtibedebova by tie proper shipping name;and are classified,packaged,
<br /> maNed and'label4placarded,and are In all respects In proper condition fortransport according to applicable intemetional6nd nallon$•I govonimenlai regula8oris.If export shipment and i am the Primary
<br /> Exporter,I certify that the contents ofthis consignment ootiforrn to the terms of ttia dthehed EPA.Aoknowiddgment of Consent.
<br /> cerl,that the waste minimization statement Identified in 40 CFR 262.27(a)(NJ dm a large quantity genwaioi)or.(b)(If t iin $tIdll quantity generator)is true.
<br /> n for ORerots nted/Typed Name Signature
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<br /> -J 16.interndtonal Shipments r-�
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<br /> Import lo'U.S.. I. 1 Export from U,S, Pori of entry/exit:
<br /> z Tiansportersignature(for exports only); pate leaving U,S::,
<br /> 17,TranspbaerAcknowledgmenio(Rece lMate4als
<br /> 0 Transporter 1 Pdnled/iypad Name Slro" C,0 . ' Montt Day Year
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<br /> Transporter 2 Priniedfryped Name Month Day Year
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<br /> i 18.Discrepancy,
<br /> 18a.Discrepancy Indication Space f--�
<br /> t_f QhanUty ❑Type ❑Residue ElPartial ReJection t
<br /> f�J Fuil Rejection
<br /> Manifest Reference Number.
<br /> j� 18b,Alternate Facility(or0eneratot) U.S.EPA ID Number
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<br /> ra+. Fadiltys Phone::
<br /> 18c,Slgna(ure olAllernale Fadl(ty(or Generator) Month Day Year
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<br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems)
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<br /> 20,Designated Facility Owner or operator:Ce•fcallon of receipt of hazarc ous materi is covered by the manifest except as need ip,8,iat1@a
<br /> Pr ntenit a erne _ ._
<br /> t YP (`fl ;! ; Signature 1 op Day Yea
<br /> EPA Fon 8700-22(Rev.3.05) Previous editidhs are obsolete, TPiANSPvRTEFi'a COPY
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