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R <br /> Please print or type.(Form.designed for use.on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> PGtorID Number, 2,Page 1 of 3 Emergency Response hone 4,Man es Tr r�klsgtN <br /> 1.Generator ,t mgi s �� <br /> UNIFORM HAZARDOUS , �� K <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> t?ilJt"t'.`i s'tf.l Sad ft i�r t,iti <br /> Generators Phone: <br /> PAID <br /> Number <br /> 6.Transporter 1 Company Name UiS E <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> 8.Desigp�ted Fac II NamBand Gi a Ad sg "''' U.S.,EPAID NurObef <br /> ! aF''t.tt�dlt:;Er t.rt <br /> FacllitysPhone <br /> ga, 9b.U.S.DOT Description(ncluding Proper Shipping Name,Hazard.Ciass,ID Number,, 1,0;contailners , .11 Total, 12.Unit, 13'Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt Nol, <br /> 1. fr!!"�1Fi�#it�fti�^}s{!�Z#�,� �"�>�1��� <br /> 13)uf �� y;,•.; r <br /> Z —27— <br /> W <br /> .W <br /> 3. <br /> 4. <br /> 14.Special Handling instructions and Additional information tt„`f S1t f's 4 � <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 classified,packaged, <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 the Primary <br /> Exporter,I certify 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 /> Generators/0 rots Printed/Typad Name <br /> Signature ,", Month Day Year <br /> -1 16.internationa Shipments. Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> re 17.Transporter Acknowledgment of Receipt of Materials ✓.� ,1 <br /> W Signature � r � Month Day Year <br /> Transggr,,leril l' (�ped Nae jff 1 f/t <br /> V. 1. �'' 1,. <br /> QTransporter 2 Pnnted/Typed Name Signature sN Month Day . Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U,S.EPA ID Number <br /> V ' <br /> L, Facility's Phone: <br /> W 18a Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling,systems) <br /> G 4. <br /> 20.De(gnatyd Facility Owner or Operator:Certification of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prin edffyp��.�,imi, f2� � ` ,i � .;� Signatu[� •-... �, Month Day Year <br /> II �.. <br /> EPA Form 8700-22(Rev.3-05) Previous editionsareobsolete. W TRA DOPY <br /> `s <br />