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Form Ap roved.OMB No.2050-0039
<br /> ase print or type.(Form designed#or rise dh elite(12 pifcli)(ypewriter. r 4,M n eat 7 a k n y b r
<br /> 2,Page 1 of '3,EiOergency Response Pgone (`+') 11 J J K
<br /> UNIFORM HAZARDOUS
<br /> 1:Generator ,Number „ «✓�`
<br /> ID
<br /> WASTE MANIFEST Generatgts, lte(�ddfees.(If different than mailing:address)
<br /> 5.Generator's Name and Mailing Address
<br /> Generators Phone: U,S.EPAdQiNurp¢ti< r I
<br /> 6,Transporter, IKamp '
<br /> U.S.�EPAIDNumber ,
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<br /> 7.T a0sporter 2 Company Name01
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<br /> (1 �! � 3 t� �'�(y �' Vii t•,k { t r4 1 �f (r
<br /> (f• ( r rvt -:,' t t ( x , . U,S.�EPAID{NUmber
<br /> 8.Peslghated,FacIIItyName and Site Address pGr "
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<br /> :tr3;Kt:aa+ (ia�"�JJ1''f.✓' ( �11/3.1" f'/f � 5p
<br /> FacilitysPhone `�y+ �
<br /> 10,Contelners. 11 Total 12 Unit , ,13•Waste Codes l
<br /> 9a. 9b.U:S;bOT Description(Including Proper Shipping Name Hazeril Class,ID Number, , N0 Type quantity Vyt Not
<br /> HM and Packing Group(If any))
<br /> G,`� �� •.par c .•t,+ .r - ,.
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<br /> DG '
<br /> W 2. -
<br /> 3.
<br /> 4,
<br /> 14.Sppglal,larft(il �Ael�ctions and Additional Information •)Z;f,,?
<br /> CERTIEIGATIONY fheteby declare;thatlha contents 0f thts,consipnmentarefuily and accuratea allonrable ovemmenbove ytal.reguthe olallons�f pO pexport shipment and i asmgthe Pdmaryd
<br /> 15. GENERA70R SIOFFEROR,S ,
<br /> marked•and jabeladipla'cardad erjd'arei H ainsisnment conform to thetermsof{he oh for attach drEPAAcknowiedgmen of Oonslent, i g
<br /> Exporter I cattily that the cor tents of th ,co g p +ear?
<br /> I cerfity that iHe waste minimtzaflon'statement Identified In 40 CFR 26227(a)(If I am a large guarltity Signature g¢(b)(If I am a small quantity generator)Is lure• Moan i
<br /> Generatorsl0fferor sdntedFfypatl Name
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<br /> F 16.intemational Shipments L---Export froml 'S,, ort f entry/exit:❑Import to U.S. L_1J
<br /> z Transporter signature(for ezpdrts only):
<br /> W 17.TransporterAcknow edgment of Receipt of Materials ^° Month`� Day
<br /> ^, Sign tUre "> >
<br /> Tranaport er1 Pdntetl ,. I
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<br /> N Signature ry7t ` tt�
<br /> a Transporte9r2Pd,#tedffypedName �, t 1 f + ,1 S t
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<br /> 18.Discrepancy
<br /> ❑Residue • Full Reaction
<br /> 18a.Discrepancy Indication Space. quantity' ❑Type.
<br /> ❑Partial Rejection
<br /> 1
<br /> 1 Manifest Reference Number
<br /> US.EPA ID Number
<br /> 18b,Alternate Facility(or Generator)
<br /> V
<br /> I facility's Phone: Month Day Year
<br /> 18c,Signature of Alternate Facility(or Generator)
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<br /> %.Hazordous Waste Report Management Method Codes(i.e„codes for hazardous waste:tieatment,diap3sel;end recycling systems)` 4
<br /> UJ 1, 2'
<br /> I l'
<br /> 20,Designated Facility Owner or Operator;Ceruflcatlon of receipt bf hazardous materials covered by the'ma gnalurecept sanded In Item 18a onl Day ear
<br /> Prints ype ams
<br /> TRANSPORTER'S COPY
<br /> EPA Form 8700-22(Rev,3.05) Previous edltions'ahe obsolete,
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