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Please pn�lt oFtype.(Form designed for use on elite(12 pitch}typewriter.) f Form Approved,OMB.No 205,00039
<br /> 1,Gene., d bey r 2, ge 1.9f 3 E ej�en�y�RasgoTe��Pt�one 4.Ma r eF#Tia kipg Numb�er'�
<br /> UNIFORM HAZARDOUS � t 4�!!t ,. _+, ' $u ;v� r ., �
<br /> WASTE MANIFEST JJ
<br /> 5 Gef} a (fi(arg9 tld Mailing Address i• Generatgrs Si`e Addref d�iJerent than'mafling address)
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<br /> Generator's Phoney
<br /> 6.Tratisp4}fer4!'ComjYarlykNeme,< U:S EPA IR ytgbaf'Oil
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<br /> 7.Trp YoPanyNamp t i 1 1. r '' 't ��:�- 4T! i US�EID(Num9be�
<br /> 8 Dag pa Qtl (i i�y'p arhe and Site Addy as U.S EPI Number
<br /> �AiN,tp.(n�e r;�;.�gP:,
<br /> lei+'lin.�"^,l'f;:if°;�.'(.t•1, b•,•�. t•�f�i3r.dr „ ,
<br /> Facility's Phone
<br /> s�� .,, U '{ ' 10.Gonfainers„ " t1 j T9tal t ' 12 Unit
<br /> „.
<br /> 98. 9b.U.S.DOT,Description(Including Proper Shipping Name t{azard Clash ID Number { 4 I&Vaste Codes
<br /> HM and Packing Group(rf any)) No.. Type Quantity Wt'l.
<br /> 1, i i t - '• .� 1 `Y'` ll•,; iii ill '� '.i�ti S i�.iC i} ��'$� r.!
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<br /> 3.
<br /> 4.
<br /> %J'bbiallHan ling instructions and Additionallnformatlon''
<br /> '4E<< 4l.tit.G''tl'
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<br /> 157 ff
<br /> 15. GENERATORISIOFFEROR'S CERTIFICATION:l!hereby declare that the contemis of this,consignment a(e fully and accurately dosed ad above by the properahipping name,and are classified,packaged,
<br /> marked and,labeledlplacarded,and ar'e'in all respects in proper condition for transport agcolding taapplicable•ij!temationaI nationai'govemmental(egulations;if e. ort shipment and I am the Primary•
<br /> Exporter,I certify that the contehis of this consignment conform to the terms of tfia attached EpAAonowietlgment of Conserit • -
<br /> 1 certifythat the waste rimmmizagon statement identified In 40 CFR 262,27(6)(if i am a Targe.quantity generator)or(b}(if a sma)I quantify generator)is true.
<br /> Generatoesl0ffergr dntedt pe Name ,'r Signature ;;w t�Johth OF tYdatr
<br /> 16.IntemailonaI Shipments ,Part of entry/exit:
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<br /> ❑Import to U.S. ❑Export.from U.S ry
<br /> Z Transporter signature(for exports only):,, j ,Date levying U;S;.
<br /> W 17.Transporter eknowledgment of Rgoetpt of Matedais )
<br /> OTransporter 1'PSi te •]!' �,,,, Signatur• ; 1 Mo D�y� }ears
<br /> z Trans'porter2 Pri ted(TyRed Name,.,, } Signature ( 7 rh` j 9 ./`1fi'� `` th, .Day (Y r
<br /> 18.Discrepancy r r
<br /> 18a.Discrepancy Indication Space E•Quantity ❑Type �Residue ❑Padw-Iejection El Full Rejection
<br /> Manliest Reference Number:
<br /> 18b,Alternate Facility(or Generator) U.S:EPA ID Number
<br /> V
<br /> tai Facility's Phone:
<br /> W 18c.Signature of Alternate Facility(or Generator) "' on Day Year
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<br /> 19.Hazardous Waste Report Management Method Codes(i.e;,codes forhazardous wasfe Ueatment;disposal,arfd recycling Systems)''.
<br /> ua 1 2,. 3.
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<br /> 20.Designated Facility Owner or Operator.,Certification of receipt of hazaM60smatedals covered by„the manifest except as noted in Item,18a
<br /> Pdnted/Type Name Signature „ Month Day Year
<br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete,' TRANSPORTER'S COPY
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