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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved OMB No 2D50=0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �[ <br /> WASTE MANIFEST f��?.�. �v' i ;,. ,1- r', ���`Jlaar 8 3 3 <:-:JJ i� <br /> 5.Generators Name and Mailing Address Generator's Site Address(If different than mailing address) <br /> - <br /> ?ii <br /> Generators Phone: <br /> 6.Transporter1�CompanyName'- U;&EPA,IDNumber <br /> '' <br /> 4:CtYvv, l.�`+frd '1tf>.. I';,sf r,'!tts <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> r11 t f �;"+.4! ttv:1;8.!:^,, j .ski"7 • <br /> Facility'sPhonei {ytw13,ea e}r ; <br /> HM 9b U.S.66f Description))eluding Proper Shi pin Name,Hazard Cla <br /> p g ss ID tJumber, „10.Containers 11sTotal 12:Unit <br /> and Packing Groupif an No. Type Quantity Wt.Nol. 13s Waste Codes <br /> Ott° .4f�t..f( "�Gtl}' XlftlGfSI}t1 Jjtf r,�. <br /> W <br /> z 2. <br /> c� <br /> 3. <br /> 4. <br /> i <br /> 14.Special Handling <br /> Instructions and Additional Information <br /> ' 3Y f <br /> )1?'ZIP <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 intemational and national govemmentai regulations,if export shipment and tam the Primary ' <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if m' mail quantity generator)Is true. <br /> GeneratpfflOfferbes PrintedRyped Na, Signa ure. y Month Day Year <br /> 16.International Shipments <br /> vw a,, (.1", <br /> i-- ❑Import J.U.S. ❑Export from U.S. Port o entry/exit <br /> Transporter signature(for exports only): Dateaving U S <br /> IX 17.Transporter Acknowledgment of Receipt of Materials <br /> oTransp�Ver}P,rintediRypedName Signature N •d' �r Month Day Year <br /> z Transporter 2 Pdnted/Typed Name SlgggtUfe `" <br /> � ,•'� m,�._ Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type <br /> ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> zi <br /> V <br /> LL Facility's Phone: <br /> Ck <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report.Management Method Codes(I.e„codes for hazardous waste treatment,disposal,'and recycling systems) <br /> LU <br /> 0 1 t J f 2. 3. 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 /> P nted/TypedName " Signature. <br /> ,- ' r' ;!: M9{t7h Day Year <br /> EPA Form 8700-22(Rev.3=05) Previous editions are obsolete. TRe4NSPORTER'S COPY <br /> I <br />