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Please print;or type.(Form designed for use on elite{12-pitch}typewriter.) For,—,Approved.OMB No 2"50-0)39 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2 Page 1 at 3 Emergency Res rise Phone 4,Man es Tra kin N mbe <br /> WASTE MaNIFEsr 9§9 f 7 2 3 J J K <br /> 5 Geste-',y, .dame ar�1 MaOtng Address Ge-eratods 5 to Ad ss dstlerent than mal ng address) <br /> Gar <br /> r r..c� <br /> Generator's Phone: `''ia�'�w i <br /> ti.Transporter I Company Name,"," -. <br /> r,k f tiv. CYrtil )pOq [1.S.EPLID�N�gbjr ' <br /> 7.Transporter 2 Company Name U S.EPA ID Number <br /> 8.De6grry1L jgg% jTaa�Cf� U.S EFA ID umber. <br /> FacE a Phone:`. '?�'n <br /> I-22ki2l-3 <br /> ga, 9b.U.S E>oT Desaiptlo (mdudm <br /> ing Proper Shippug Nae,Hazard Class,JD Number, 10.Containers 11 Total 12.Unit <br /> HM and Packing Group Of any)} <br /> No. Type Quantity WtNoL 13 Waste Codes <br /> f 1. MON R1:;rPr Frp714';;"r <br /> O ,^ <br /> �F,'ti,ti7r_ s�tdrt a�S��"t3T; a w- <br /> 2 <br /> 3, <br /> 4 <br /> 14.Special Handling InstruGions and Additional Information <br /> 15. GENERAMR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping <br /> marked snd�beledlptacarded,and are in an respects In proper condido,for trans Itxp name,and are d I ssised,packaged <br /> part according to kmWe6te ens of tions end national governmental regulations If export shipment and"I am the Primary <br /> Exporter,1c;%that the contents of fhis oorastgnmenl nonfarm 6o the teens of the attached EPA Acksaowledgment of Consent. <br /> I testify Brat the waste minimmlakon statement Iden5ed in 40 CFR 26227(a)(f I am a large quantity generator)or(b)(H I am a small quantity g rentor)is true <br /> Generator e(0iferor's Prin yped Hama Signature M pth Day Year <br /> 18.International Shipments <br /> ❑import to U.S. ❑Export from U.S. %f Pod of entrylextt <br /> Transporter signature(for exports only): Export <br /> leaving U.S. <br /> 17.Transpade!pdaaowledpment of Receipt of Materials r <br /> Signature _ Day Year <br /> Tren :��ti 1Tr4amelr� ' r� <br /> a Transporter 2 Printed/Typed Name Signature ! { <br /> �C Mouth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indicatlon Space j <br /> Quantity ❑Type ❑Residue ❑Partai Rejection ❑Full Rejection <br /> 18b.Alternate Faa7 ty for Generator) ManHast Reference Number <br /> US EPA iDNumber <br /> t3 <br /> Fadiity's Phone• <br /> 18c Signature ofMamate Fac lily;or Generator) <br /> Z Month Day Year <br /> cn19.Hazardgus}Haste Report Management Method Codes{i.e,codes for hazardous waste treatment,disposal,and racycnng systems. <br /> a <br /> t %f / 2. 3 <br /> / a, <br /> 20`Qesignated FacAty Owner gr OpeW..Certification of receipt of hazardous materials covered by the manifest except as noted(n Item 18a <br /> ►thtedfl Na�e� f, ! Signature <br /> onth -' py 'Year <br /> EPA Form 8700.22(Rev 3.051 Previous editions are obsolete. <br /> r f1. w j f <br /> TRANSPORTER'S COPY <br />