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Please print or type.(Form designed for use on elite(12-pitch)typewriter) "- Form Approved.OMS No.2059 t7U39 <br /> UNIFORM fiA7ARl?OUS 1.Generator ID Numtler _ 2.Para 1 of 3.Emergency Response Phone 4,Ma es T kin l lum(te ; <br /> WASTE MANIFESTCj�i/ �$�Fl r'i .3ri �Gl f-L�I 818 JJ K <br /> 5.Generator's Name and Man'mg Address / Y. �r `Generators Site Address Of d3ferent than ma7ing address) <br /> e 1 ewo <br /> enereta Phone: , <br /> B.Transporter TCom any Name :. U.S.EPA 1D Nprttber <br /> Li�Gral$�,. fl<11f3f i1i �kl.l�:!• <br /> 7. ransporter 2 Company Nam s U,S.EPA ID Number`~ <br /> t L. r�, t '� <br /> 8.DaSlgdliNFb UVNaW tWSit§Address �. <br /> ,' t,�h t U,5 EPA ID Number 7 <br /> lift# 112 <br /> Fadii s Phone!- <br /> .'-. <br /> 9a, 9b.U.S.DOT Desaiptlon(ndudlr4 Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(f any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity WLNol. <br /> A 1. i'-!'Itjtlf"i tL"!.scrSiJ4 u .c ss.Klu r�!rY r�yv,w•a, rwtvrif w;, w� <br /> O <br /> I.Yr .cth :un oaf^a r.. <br /> ILII -- <br /> C9 <br /> 3. <br /> 4. <br /> 14x5 1 a�dli�rg lnstructicns and Addittanal lnfomnali non <br /> 9-0.3'y <br /> 15. GENERATOR'fSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassifsed,packaged, <br /> mado d and Isbeledrptacarded,and are in atf respects In proper condition for transport according to apprIcable international and national governmental regulations.It <br /> Exporter,I caddy that the contents of this oDnsigrimt.~1t conform to the terms of the attached EPA Acknowledgment of Consent a rt shipment and t am the Primary <br /> I certify that the wsses inkhmiz6on statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)Of i am a small quantity generator)Is he, <br /> GeneratbtsUffeia's PdntRUTyped Nam Signature <br /> _ Month Day Year <br /> --r 18. Ptemalionaf Shipments ❑ <br /> I <br /> porters' nature for ❑Import to U.S. Export from U.S. -� Port of entrylexit <br /> Trans re ( exports only)' Data leaving U.S.: <br /> 17.Transporter AdT&Medgment of Receipt of Materials <br /> Transporter i Prin ame Signature <br /> f Manch Day Year <br /> rn r, Q 1 f�/ IJ 7�s <br /> Z Transpj iter 2 PrintedlTyped Name + y <br /> Signature <br /> [ - f �. Month Day Year <br /> � <br /> 18.Discrepancys ), ` ,�.� <br /> I ' <br /> 1 Ba.Discrepancy lndipiron Space �. <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fun Rejection <br /> 18b.Aftemate Fadtity(or Generator) Manifest Reference Number. <br /> U.S,EPA i0 Number <br /> ++d. FadGlys Phone: <br /> i ac.Signature of AltanlatB Facfitty(or Generator) <br /> z Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes;i.e.,codes for hazardous waste treatment,dispose and racycfing system) <br /> Lu <br /> im 1 2 3 4. <br /> 20.Designated Fad?ty Owner or Operator Certification of receipt of hazardous matadais covered by the manifest except as rioter'n Item 18a <br /> PriniedlTyped Name I <br /> SignatureMonth Day Year <br /> Form 8700.22(Rev,3.05) Previous editions are obsolete <br /> TRANSPORTER'S COPY <br />