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Please print or type..(Form designed for use on elite(12 pitch)typewriter) <br /> 1.Generator ID,Number Form Approved.OMB No.A0 0.0039 <br /> UNIFORM HAZARDOUS t 2.P ge 1 of '3.Emerggcy Response P.,(tone 4.M i est Tra king Num er x <br /> WASTE MANIFEST J7 r , g asr' <br /> 5 Getier%ors1Nama apd Mailing AddressGenerator's 5)teAddress(ffdif(erentthan mailing address), <br /> Generator's Phone: <br /> 6.Transporter 1 Com an N <br /> Gr„4c vim, Pa �?'r <br /> U S.'EPAID Nu ber{;- <br /> 7.I tf ,rahsporter 2 Company Name r. i II ?? <br /> EPA ID Numbed., <br /> 8 Des;gnaled FaLyhlg Name4and Site Address <br /> '_ r ',t 1,.FF.`.: U.S.EPA•tqNprpber;.., <br /> Facility's Phone: <br /> ga, 96 U s.DOT Description(mcludmg Propershippmg Name Hazard Class ID Numtier 10.Containers. <br /> HM and Packing Group(if any)) 11.Total 12 Unit 13,Waste Codes <br /> No Type, Quantity Wt Nol. <br /> OG > <br /> LU 2. <br /> t,.9 <br /> 4. <br /> 14.S�ep(al(tan Iing I_4ructions and-Additional Information <br /> 15, GENERQTORWOFFEROR'S CERTIFIQATION; f hereby declare that the contents of this consignment are fully:and aocpfately descritietl above by;iha ro e shl 1 <br /> marked and lefieled/piacaMed,andira in ell respects In proper condition for trans`port...... tling,to a Ifoelile Infematio e " ' ? ,?r•hipping name and are;classified;packagetl,' <br /> Fxporte'r,I certify'that the contents`of this consignment conform to the ferins of the,attached'EPAAclmowledg'ment of Conser d natlonet govemmerifa)regulations,If exportsfiipmentantll amlhe Primary <br /> I certify that the waste miriimlzatiori statement Identffietl In.40 CFR 262;27(a)(Ifd am n lerge,queritity generator)or j�(ff am'f mall qu tlty gen¢ratoj)is true; <br /> Generator's/0ffe 9s.Ppd a ypedtNam" I 'S } <br /> ti 1 K.. �9lgnature <br /> „ _ <br /> 16.Intemationai Shipments <br /> ❑Import to U.S. ❑Fxporikom U.S, Poit;of entry/exit: <br /> 2 Transporter signature(for exports only): • -• • <br /> LU 17.TransporterAcknowletl�ment of Receipt of/M(ateHais Dateaeavmg U S,r; <br /> 0 Transporter 1 Prig e 8 N�me d�f l ` . 1` ' <br /> S Signature Mgnt Da <br /> IL <br /> � r'', 4ar <br /> Z (ransporter 2 Fnmed/Typed Name t "V ' <br /> ¢ 1lli Signature: d n <br /> p <br /> ,Day �ear <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> El Quantity ❑Type ,❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) - Manifest Reference Number. _ <br /> -� U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) <br /> Z Month Day• Year., <br /> g ste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> cility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> e Signature <br /> Month Day Year <br /> PA Form 8700-22(Rev:3-05)Previous editions are obsolete, <br /> TRANSPORTER'S COPY <br />