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Please print or type.(Form designed for use on elite(12-pitch);typewriter.) Form Approved.OMB No 2015 0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone' 4:Manifest Tracking Numb .1 <br /> 776 4A <br /> WASTE MANIFEST y <br /> 5 Generator s Nave and Mailing Address "'' 'Generators Sita Address(ff different than mailing address) <br /> TOM r <br /> 9tr.l1'), 1 t gra° <br /> Generators Phone: <br /> 6.Transportert0ompanyName' w U:SrEPAIDNumber <br /> T.Transporter 2 Company Name <br /> UU3.EPA ID Number <br /> 8 Designated Facrhl Na e,anH Sfte Ad ess U.S EPA ID Number <br /> F r�S°d ` :. <br /> I s.. <br /> Facllity's Phoneu"w'� a , <br /> F9a. 9b.U.S,DOT Description(includingProper Shipping Name„Hazard Class,ID,NumbeX, „ pntalners,;;; „+„tz11 Total r ;, 12'Unitf Jae*aste Codes <br /> and Packing Group(If any)) No. Type Quantity Wt Nol, <br /> 1• �3F?Stl �xY°rF�.a.'rk ;�tt1§�'�:1 r`��4''..a i� 4�')t.ti� YZ;,H.:�. �.��:i_t�Z;�'t�t+tl s t r 1 fit, + a 3t� ,1 � f?r i° i <br /> Z. <br /> LU <br /> 3 N! lit i <br /> W • Ii. t• . ;•� y4. 7jk„ <br /> 1 t <br /> 3. <br /> 4, <br /> 14,Special Handling Instructions and Additional Information• y <br /> 3 d;�•f,r tJf g�.� lv�+��, r�� <br /> 15: GENERATOR'SIOFFEROR'S CERTIFICATION: i hereby.declare Met the contents of this consignment are fully and accurately described shove by the proper shipping name,and ere,c�assifed,packaged <br /> marked andlabeledlplacardetl,and are in all respects in proper condition fortransport according to applicable lntemational and national govemmental regulations,If export shlpmenf and i am'ihe Rtimary, <br /> ExportiMv certify that the contents of this consignment conform'to the terms of the attached EPAAcknowledgment of Consent. <br /> I'certify thaft,he waste minimization statement identified in 40 CFR 262.27.(a)I(if I am a large quantity generator)or(b)(if I am:a small quantity generator)Is true, µ, „ <br /> GeneratorslOfferors,Printetl/Typed Name Signature g Month Day• 'Year. <br /> 116.Intemational Shipments F import to U.S. ❑Export from U.S. Port of•13ntrylexit: <br /> r` Date leaving U.S.: . <br /> z Transportersignature,(for exports only): <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 P nt dlType Name,. Signature +, Month Day Year <br /> p �, ��• ,�.�� d�,i f f d <br /> Signature Month Day Year <br /> z Transporter 2 PnntediTyped Name 9 <br /> N <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Refection Full R-1-cUon <br /> Manifest Reference Number, <br /> 18b.Alternate Facility(or Generator) U.S.EPA IDNumber <br /> J <br /> v <br /> Facility's Phone: <br /> w 18c.Signature'ofAltemateFacility(or.Generator) <br /> Month Day. Year <br /> a <br /> z .. <br /> 19.Ha 'oue;Was 6 R port Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 4. <br /> o 2 <br /> •f ;, r ; 3. <br /> 20.Des(gnatq Facility Owner or OperatorX dificatio rof receiptiof hazardous materials covered by the manifest except as noted In ftem 18a <br /> Printedffy rr Naaf ,t Signature (! J f` �+°�Mohila - Day Ye r/ <br /> EPA Fortin 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S.COPY <br />