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Please print or type.(Form designed for use on elite(12-pitch)typewriter,) Form Approved.OM6 Ns.,205.0,`-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page t of 3 Emergency Response Phone 4,Manifest TrackNumber v y <br /> WASTE MANIFEST °� A > <br /> " � � t: JJ <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Sri <br /> Generator's Phone: <br /> 6.Transporter'J Company Name U.S.EPA ID Number <br /> lt'{Star•1t' <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Faplrlty Na a and Site Address. <br /> is U.S.EPA ID Number <br /> Facllity's Phone: n i <br /> ga, 9b,,U,S,DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WtNol. <br /> � 1 h'7r,rrrr r t. <br /> t <br /> y/] <br /> w <br /> 3. <br /> 4. <br /> 14 Special Handling Instructions and Additional Information <br /> t f .!.+ <br /> f <br /> i 15. GENERATORVOFFEROR'S CERTIFICATION: I h reby declare that the contents of this consignment are fully and accurately described above by the proper shipping game,and are classified,packaged, <br />! marked and labeled/placarded and'are in all respects`n proper condition for transport accordingto applicable Internatio�nai nd national govern°ental regulations.if exert shipment and I am the Primary <br />' Exporter,I certify that the contents of this cohsignmen conform to the terms of the attached EPA <br /> Acknowledgment of Cense t. t <br /> I certify that lhe.Wa'ste minimiz bon statementldenNfie n 4 CFR 262.27 a if I am a large uanH <br /> �. O( g q ty generator)or(b)�dl am small quantity g aerator)is true. ,> <br /> General ds/OffeYors Pdnted/Ty�d Name" Signature,-': '* <br /> (� y 1 ¢ <br /> y � Day+ Year <br /> w, M <br /> r f1 <br /> u 16,International Shipmentsa 6 ( i <br /> Z ❑IrnEwrt to.(1 S ❑Export from U.S. W of entry/exit:d ' <br /> Transporter signature(for exports only): f� a leaving U.S.: " <br /> 17.TranspoderAcknowledgmentof Receiptp)MaterialsLU <br /> ' <br /> Transporter 1 Printed/Typed Name - f it Signature. ` <br /> Day Year <br /> h <br /> M L...�• j <br /> Transporter 2-Printed/Typed Name ` Signature Month Day Year <br /> F- 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type YP ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> tQi Facility's Phone: <br /> W 18c.Signature ofAlternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1• 2. 34.. <br /> it <br /> 20,Designated Facility Owner or Operator:Ceitication of receipt of hazardous materials covered by the manifest except as noted in Item Ise <br /> Printed/Typed Name l r <br /> Signature", Month Day Year <br /> EPA Form 8700.22(Rev,3.05) Previous editions are obsolete. TRgPVSPORTER'S COPY <br />