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Please print or type.(Form designed for use on elite(12-pitch)typewriter.)—, Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of Emergency Response Phone 4.Ma Tr5pklng Num§er <br /> WASTE MANIFEST (,1 <br /> 5.Generator's Name and Mailing Address er, Address(if different than mailing address) <br /> ti e";'hi <br /> Generator's Phone: <br /> 6.TraOspoder 1,0?mpan�Name U.S.EPA ID Number <br /> 7. ranporter 2 Company Name,• U.S.EPA ID Number <br /> 8.De'sf§dhtbd P%dlIV,,N9mefi6d-'SIta Address U.S.EPA ID.Number <br /> 'A <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No Quantity Wt.Nol. <br /> 0 <br /> Z <br /> Uj <br /> 3. <br /> 4. <br /> 114,$FIRIVldllpg Instructions-and pddltionaIInformation <br /> V, <br /> iee9 3 <br /> 15. GENERATOR'SlOFFEROR'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,p a'ckaged, <br /> marked and labeled/placarded,and are afres e6ts in proper condition,for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Expbrtdrj'6ed1ty'thatIh6 contents 0 isconsignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certilyjl�1 0 t5bs)v a.slemIn! "Aim statement I entitled In <br /> n 40 CFR 262..27(a)(if I am a large quantity,generator)or(b)(if I am a small quantity generator)is true. <br /> Generat6es/Offerdes Printedfryped Nam Signature <br /> Month Day Year <br /> t .lav11 16'. <br /> -J16,International Shipments <br /> P- 1:1 Import to U.S, El Export from U.S, Pod of entry/exit: <br /> Z Transporter signature(for exports only): <br /> Date leaving U,S.: <br /> W17.Tr6nspoderA6kn6wlbdgment of Receipt of Materials <br /> E2 Transporter I Prinlpdped Name <br /> Signature <br /> Month Day- Year <br /> 0 <br /> V. <br /> co <br /> Transporter 2 Printed/typed Name Signature / tryMonth Day Year <br /> 31—, '-, e f /V <br /> V <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ <br /> Quantity ❑Type El Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U,S.EPA ID Number <br /> Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) <br /> Wnth Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj <br /> 2. .73, <br /> 4. <br /> ............. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 'Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, <br /> TRANSPORTIER'S COPY <br />