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1 Form Approved.OMB No.2050.0039 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> 11NIFORM HAZARDOUS �•Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4 Manif14 <br /> estTracking Number <br /> F1WASTE MANIFEST € _ d ��v d` .. a 4 t r, g , "I o 1 r , , _. ._ '$ �� <br /> 5.Generator's Na a and Mailing Address Generators Site Address(if different than mailing address) <br /> T <br /> 4114 4v <br /> Generators Phone: V 1r a rod <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> (" o t 1k?\ttif_ l j _.r ific 1 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Des' to Facll (Jame Site F)ddr�s U S EPA ID Number <br /> Facility's Phone: ri i-n,£'•v'`3 <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 /> iYt { M <br /> dlrfs;=�1._ ;r��lf+ fQIY� ilr,°tit°.:'fY <br /> o _, <br /> 2. <br /> 3. <br /> YOUR COPS <br /> 4. G-3ekain Or 3 years frorn <br /> 411 /Ofcc cute. <br /> 14.Special Handling Instructions and Additional Information <br /> 'Y.t,n.rt�FE ik.��.€S . „ °.f=r <br /> 15. GENERATOR'SIOFFEROR'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 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 I am a smal°(%quantity,generator)is true. <br /> Generators/Offeror' Printed/Ty ed Name Signatu fQ Month Day Year <br /> Voi) <br /> �n <br /> —J 16.International Shipments=,,. tr " <br /> ❑Iropoft to U.S. Export from U.S. Port ofntryxit: <br /> F= Transporter signature(for exports only): Y' Date Ieawngb S.: <br /> Ix 17.Transporter Acknowledgment of Receipt of Materials <br /> UJ <br /> G Transppr(arliirinte,lTyped Name Signature P Month Day Year <br /> { C <br /> BTransporter 2 Printed/Typed Name Signature`" C ,n Month Day Year <br /> tr <br /> t-- <br /> 18.Discrepancy <br /> i 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone; Month Da Year <br /> w 18c.Signature of Alternate Facility(or Generator) Y <br /> B <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ® 1 2. 3, 4...._ <br /> 7 <br /> 20.Designated Facility Owner or Operator;Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Signature Month Day Year <br /> Name �° � 4 <br /> p <br /> XiV <br /> EPA Form 8700-22 Rev,3.05 Previous editions Are obsolete, E916NATEDD FACILITY TO GENERATOR <br />