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Please print or type..(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OM8 No.'200 0039
<br /> I.Generatot D pial§eater 2�P ge 1 of 3 E e[ge)r�y fje�pnns�P��iona 4.M +est T kf�ng N m�perg� J J i\
<br /> UNIFORM HAZARDOUS �r.to4 ,: ., it 3 ted. .�•r,,,)15 e�
<br /> WASTE MANIFEST •te'Add,�re�yys ,�:grent than mailing address
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<br /> 5:%ftgltitoBj+N feet d Mailing Address ltf dfr!r� )
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<br /> Generators Phone:
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<br /> 7. sPoe2 Company NamM,
<br /> 8 Desiri'naTed7F II Nartfe+and Site Address ;zJ, U.S EPA lq�umbe(11,:
<br /> Facility's Phone
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<br /> ga 9b.U,S.d01 DesoripUort(mcluding'ProperShippind Name Hazzard,Class;)ID Number 10..Gohla{Hers i. 11)Totah 12 Unit 13'.Waste Codes
<br /> HM and Packing Group(If any)) N9. Type„ Quantity Wt,N,oi.
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<br /> 14 Gne ai lig til r�g,in tructions,and-Additional Information
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<br /> 16. GENERATOR110FFEROR'S;CERTIFICATION: thereby declare that the contents of this wnslgnment,are fully and acopfately dasCribeiJ above bytha prop7,shipping name ani ore`clsssffled,packaged,
<br /> marked and letieledlplacarded,and aTe in all respects in proper condition for Uahepoit'accordIn" to ipplicalile Interfiaflonat'a�'naflonal, bye,rnmegfal regulaflonsfif export siiipmentantl'I am the Primary
<br /> Exporter,I ce tity that the contents of this consignment conform4o the'temis of the attached EPAAckn6WIddgment f`Consen �
<br /> i certify that the waste minimization statement identifla In.40 CFR 262,27(x)(If I am a large quantity generator)o( )(If I t�mlaigmall qu tlty� ngret4)Is true, q
<br /> Generatotsl0'1 ods lt(e ype�,Narii • f�i 9lgnature ; e?I `y po ly I
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<br /> F 16,International Shipments
<br /> ❑impoittoU.S.. ':'�Exporf'(fomU.S. Port ofentrylexit;
<br /> — Transporter,signature for exports te.leaving,US., ,
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<br /> � 17 Transporter4MowiedgrhentofRece .tofMatedals "" �'r ✓ ' '
<br /> U.1 signature M n Da ar
<br /> i Transporter 1 PH edlTy a me a+�. c g 'rvir,.7
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<br /> l z prisponer 2 PrigledfTyaeed Name 4,, "?.. Ly t �•rw t.' Signa Vol",°
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<br /> 18.Discrepancy y :
<br /> 18a.Discrepancy Indication Space QuanOty Type" ❑Residue 0 Partial Rejection ❑Full Rejection
<br /> Manifest Re ference•Nrrmber.
<br /> 18b,Alternate Facility
<br /> (or Generator) U.S.'EPA ID Number
<br /> FacilitysPhone:
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<br /> 18c.Signature of Alternate Facility(or Generator) Month. Day Year r
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<br /> N 19.Hazardous Waste Report Management Method Codes(i.e., odes for hazordous waste treatment,disposal,and recycling systems)
<br /> 0 1, 2. 13., 4.
<br /> 20.Designated Facility Owner.or Operator.Certification of receipt of-hazardous materials covered by the manifest except as noted in Item 18a
<br /> Pdntedffyped Neme q„. Signature, Month Day Year
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<br /> EPA Form 8700-22(Rev.3=05)`'Previous editions are obsolete.`' TRANSPORTER'S'COPY
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