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Please print or type (Form designed For use on elite(12-pitch)typewriter Form Approved.016 No 2v5Q-�,.3: <br /> UNIFORM HAZARDOUS 1 Generator IO Number 2 P�qa 1 of 3 Emergency Res)-r.;n Phone 4.MUffest Tracking Number <br /> WASTE MANIFEST r d _6 9$7 5 JJ K <br /> 5.Genfutators�Name and Malltng Address Ge eretor s Site Adv rens{if differenl than ma ng address) <br /> Generators Phone: <br /> 6.TranspoRer 1 Company Name U,S.EPAlDNum r <br /> Geo: a Al ,,_;r iR ' <br /> 7.T nsporter 2 Company Name U.S EFA ID Number <br /> 8.Desigr��ted F)eiy Name. r1d Sft�gtldn ss U.S.EPA D Number <br /> 27, L "r <br /> Fatty's Phone: <br /> ga. 9b.U.S.DOT Desaiptian{ndud'ug Proper Shipping Name,Hazard Gass,10 Number 10 Containers <br /> FIM and Packing Group(d airy)) 11 Tota 12.Unit 13.Writs Codes <br /> No Type Quantity Wt1Vol. <br /> 1. r'"t1 FtGF•a9PL• 3 t3tr s T� rx } d, i �r,rr+l� 1? <br /> w <br /> z 2. <br /> w <br /> to <br /> 3. <br /> a. <br /> P4'5pecial Handling Instructions andAdditiona!infomeaUon <br /> r I <br /> 15. GENERATOR S10FFEROR S,CER71FICATION:�I hereby declare that the contents of this consignment are fuuy and accurately described above by the proper shipping name.ani are classified packaged, <br /> marked and labeledlplaearded,and are fn all resp Jn proper condition for transport according to applicable International and national ovemmenlal <br /> Exporter,l certify 1Gt the contents of this oon�gnr>tient conform tolthe terms of the attached EPAAcknawledgment of Consent. g regulations If export shipment end I am the Primary <br /> I certify that fie waste minimization sta{eme tkt�nWAl In a0 CFR 282.27(a)(d 1 am a large quantity generator)or(b)('df am a 3=1 quantity generator)is true <br /> GeneratorsOfferoes Pdntedlryped Name f' Signature <br /> .� M �� Year <br /> 1 16,Iniemational Shipments <br /> Transporter signature for Ejfmport to U.S ❑Export from U S Part of entrylexlt <br /> T f { Thr): <br /> Data leaving U.S.: <br /> 17 TransporterAcfmowtedgmant of Receipt of Materials <br /> Transporter) yped N ` /P <br /> a �rry 74 f V Signature �� M�o�pyth Day Y. <br /> QTransporter 2 PrintedlTyped Name 1( f <br /> Signature +' Month Day Year <br /> 18.Discrepancy r <br /> 1Ba.Discrepancy indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑F.1 Rejecilan <br /> 18b AN,emate Facil'dy{or Generator) Manliest Reference Number. <br /> U.S.EPA ID Number <br /> U <br /> L Faalitys Phone: <br /> 18c.Signature of Aherlate Faciaty(or Generator) <br /> Month Day Year <br /> 35 19.Hazardous Waste Report Management Method Codes 0,6.,codes for hazardous waste treatment disposal.and recycling systems, <br /> cm 1 2. 3 <br /> a <br /> E - <br /> 20Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as ncted n hero 1 Be <br /> Name <br /> Signature Mono Day Year <br /> EPA Form 8700-22(Rev 3-05) Previous editions are obsolete <br /> TRANSPORTER'S COPY <br />