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Please print or type,(Form designed for'usa on elite(12-pitch)typewriter,) ,Form Approved,OMB No.2850 0 39. <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 erg <br /> Emency Response Phone 4,Manifest Tragkin Nu Th772' 3 <br /> 7 2' 3 JA <br /> -r i't(kr� ,.., r t � .e &A 4d rvJ 7 <br /> WASTE MANIFEST <br /> 5 Ge r l j ame�rtd Mailing Address Generator's Site Address If different than mailing address) <br /> Generators Phone: q,cF }d+,r"1aa sL <br /> 6.Transporter 1�Company Name' U.S <br /> trt7.ii}.. "T <br /> t+Wty+,df1:Gr <br /> 7,Transporter 2 Company Name U.S.EPA ID Number <br /> B.DetF,�� i ? ali ;; �ei �'. kestnd. U.S EPA IDNum�er <br /> if;;'l9 f'. i""•}i•<,tJt 1t7�+t�t: },tt <br /> Facililys Phone;, <br /> ga. 9b U S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers , 1L Total 12,Unit 19.'Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity Wt.Nol. <br /> W2 <br /> 3. <br /> 4; <br /> 14.Special Handling Instructionsand Additional information <br /> S <br /> 15. GENERATOWSIOPFEROit' CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aM are classified,packaged, <br /> marked•and la6eledlpiacarded,and are n 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,waste'Ipinlmization statement identified In 40 CFR 26227(a)(It I am a large quantity generator)or(b)(if I am a small quantity g(Aerator)Is true. <br /> • Generators ffeYo{ft Pdhted yped Nem�e�rrt Signature ; f �' /' Mgplh Day f Year <br /> 016.InternationalShIpme.rits S.0 Importto U.S. ❑Export from U.S,;,'r' Port of entrylexit: <br /> Transporter signature(for exports only): ,1 r Date leaving U.S.: <br /> W 17.TransporterAcknowledbrn rpt of Receipt of Materials , <br /> H Signature r Monjh Day Year <br /> � Transporters rintedfi'y e�Natne 9 ,�.';r <br /> a PP''C1r 1 ,•• p ; ear <br /> QTransporter 2 PrintePyped Name Signature Month Day Year <br /> 18.Discrepancy. . <br /> 188,Discrepancy Indication Spate � 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 /> W Facilitys Phone: Month Day Yeaf <br /> W 188 Signature of Alternate Facility(or Generator) <br /> Q <br /> z <br /> 19.Hq6td9usyVaste.Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 i.-".. ( 2• 3' 14, <br /> I <br /> 2 f esf dated Fa illty 0*.nargr Qp(#Aor:Ser1IflcatIcp of receipt of hazardous materials covered by the manifest except as noted in Item 18a !+. <br /> P to R a e <br /> Sign at re f ,r r onth D.y, Year <br /> y/ <br /> ! r/r ` f1 <br /> •f, <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. 'TRACOPY <br />