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Please p-:,tor type {Form designed for use on erite(i2-pitch)typewriter t` Form Approved.OMB No 2050-0039 <br /> UNIFORM ASTE HAZARDOUS 1 generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Maan015864853 <br /> Efast Tricking Number <br /> WASTE MANIFESs-Kameand 015 8 8 4 8 5 3 JJ K <br /> 5 Generate s 2�xr, and ides rsg Address Gener"s SiteAddress(rf different than noTng address. <br /> E��t <br /> Of, <br /> lGenefatofsPhone: 3- <br /> 6.Transporter 1 Comparry.Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name - I U,5.EPA 11)Number r { <br /> B.Designated adGur U 'j tAf.-I-f 4 . <br /> U.S.EPA ID Number fy . <br /> FaaTiVs Phone: <br /> 9a. 9b.U.S.DOT Uescrrdud(inctuding Proper Shipperg Name,Hazard Class,ID Number 10 Containers <br /> HM and PacWN Gnxrp tdany)) 11.Total: 12 Unit <br /> No. Type Quantity WLNol 13,Waste Godes <br /> C 1 3 F'sL �,T�av�f4rJCtLitffT£ .fD - f . �...� s . �c}iil j <br /> i 2. <br /> LU <br /> C'S - <br /> 3. <br /> 4 <br /> 14:Sip [H�andGng Urshuctlons and Additional Inio=bDn <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of thimirked ands consignment are fully and accurately described above by the prnper shipping Hama,and are classified,packaged, <br /> tabeied'PoaFakporte I certify MatMe riled,acontentn dnd am Ft 21 respects in proper Condition for transport according to appkabie International and national governmental regulations.if e.,gmd shipment and I am the Primary <br /> consignment mnfam to the terns of the attadred EPAAdmowiedgment of Consent <br /> 10&*drat the waste rnirdmtzatlon statementidentified in 40 GFR 25237(a)(f<I am a large quantity generator)or(b)fill am a small quantity generator)is true. <br /> Genera6ofsl0lferoxs FkYr yped Name ,r Signatisre <br /> / 1" C- f ?� Year <br /> F- 16.International SMpments <br /> ❑Import to U.S. ❑Export from U.S. Pat of errWexit <br /> a Transporter stgnatuia(for exports only):, 1 Jf Date leaving U.S.: <br /> 17.Transpate�grnent of Receipt of Mah-Igs <br /> Trarrspo(tera.P.AaTaQlTy ped Name I <br /> Sfgnture Manch Raycri <br /> 1�ear <br /> Z <br /> Trarls�orter2 PrintedTyped Name r _ •'� r <br /> ~� 1 .r 7 V f Sigoater f ` J Q j Ypar <br /> 18.Discrepancy t <br /> 18a,Discrepancy Indication Space <br /> Quant y Type ❑Residue ❑Partial Rejctin <br /> eo <br /> - ❑Ful Rejection <br /> 1Bb.Alternate facifty(es Generator} Manifest Reference Number, <br /> --r U.S.EPA ID Number <br /> V <br /> It Facility's Phone: <br /> 100.Signatvra of Alternate Facility(or Generates) <br /> Q Month Day Year <br /> 19 <br /> CO3 Hazardous Waste Report Management Method Codes(i.e,.codes for hazardous waste treatment disposal,and in <br /> C 1 2 recyd g systems) <br /> 3. 4. <br /> 20,Designated FaciRy Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as need in item 18a <br /> PrintedlTyped Name <br /> Signature Month Day Year <br /> EPA Farm 8700-22(Rev.3-05) Previous e I ons are obsolete. <br /> TRANSPORTER'S COPY <br />