|
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 3 Em e geno Response Phone 4.Manifest Tracking Number
<br /> WASTE MANIFEST , . .j+ t � $iw � '.�} y � �'111 1 '�� 'P 0 K d��1 t JJ K
<br /> 5,,Ggneratoes Name and alling Address Generator's SlteAddress(if different than mailing address)
<br /> e�. "
<br /> d �„ r iy fwd
<br /> s CEJ tc�" �. dN�
<br /> Generators Phone
<br /> 6.Transporter I�Company Name U.S.EPA ID Number
<br /> „ �
<br /> 7.Transporter 2 Company Name U,S.EPA ID Number
<br /> 8,Des)gnated,(aC ;el ; U.S.EPA ID Number
<br /> Facility's Phone:'
<br /> 9a. 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. Type Quantity Wt.Nol.
<br /> ; 1. I',tCSP�ttf!',"ins"@{rer...itPr¢�tJlt� 6tj,1;,,'�r! f;'1af.iC1 l,��i,r zrtt„,,ter"t�It1x?ffi;, :r;}
<br /> W 2
<br /> W
<br /> --
<br /> 3,
<br /> 4.
<br /> 14.Special Handjing Instructions and Additional Information
<br /> `W
<br /> 15. GENERATOR'S/OFFEROR'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 wasteminimization statement Identified in 40 CFR 262,27(x)(if I am a large quantity generator)or(b)(If I am a small quar)(ity generator)is true.
<br /> G ato Offertors Pdntedfrypyed Name I nature { Moplh Day, Year
<br /> —r 16.International Shipments i
<br /> F ( impo to U.S, ❑Export from U.S. Port ofentry/ex
<br /> Z— Transporter signature(for exports only): VDate leaving U.S',:
<br /> W 17.TranspoderAcknowledSment of Receipt of Materials
<br /> t2 Transporter 1 PrinwfirTypegarne , w,, Signatufe ;� MAr1(h Dea ay, r
<br />(( ,J"+�'yJy ff M-' � �, �}
<br /> i OO. .,.? „3,1 ,1,d`..�9" ....,,.,.Y,, 'V�'f'°j •�L« '°"" " 'rwNi°'` �,N•�%' .... `w � i C,!"a+} 4#E.'rj'
<br /> Ik Q Transporter 2Printed/TypedName .,,,$19nature"" � •�”""`" Month Day Year
<br /> I-
<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 /> J
<br /> CV
<br /> ua. Facillty's Phone:
<br /> w 18c,Signature of Alternate Facility(or Generator) Month Day Year
<br /> viya� 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 2. 3, 4,
<br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials'covered by.ihe manifest except as noted in Item 188
<br />`
<br /> PdntedrryR-qO ame Signature r'' Month Day or
<br /> 1{�+'y
<br /> ......../ •"P �eP7 �../ ,,.,w�Ef, rl• 4..'i Yr 1p'f'�', •wr.M. t" i
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, TRANSPORTER'S COPY
<br />
|