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S <br /> Pfease print or type.{Form des) ned for,use on elite;l2 pitch}yter.) Form droved.OMS No 2050-0039 <br /> FUNIFORMRI}OU5 1 Germ�a�..� `ti"� 2._89e 1 of 3 Eme ge.nay�orawne �. r GEST trrj,�MaNngAddress Generatgsl �J C.- <br /> . <br /> Generator's Phone: <br /> 6.Tra pgye llrt°mp,Wya ft b U.S.EPAt JNura6ar-n; ; <br /> 7.Tri st +L r 2 Company Name <br /> 8. -fed$S_dii�artie'Ar�SiteAddress U.S.EPA�yN +�,*� <br /> IC . .,1 <br /> i Irl L? 6SM5 <br /> parr=:,4. <br /> Fab;rr's Phone: <br /> 9a. 1 9b U.5,DOT DMZPbOn(soiudmg Proper Shipping Name,Hazard passer, 10 Containers <br /> ,ID Numb <br /> HM and Packing Group(if any)) 11.Tata) 12 Unit 13.Waste Graces <br /> No TyRe. Quantity WuVol. — <br /> ce <br /> t 3� <br /> W <br /> lu 2. <br /> L,I <br /> C� <br /> 3 <br /> 4. <br /> 14.Sgec�at !agtr�r truccGons andAdditM tnformatlan <br /> 15 GENERATOR'VOFPEROR'S CF MFICATION: I hereby dedare that the contents of thh <br /> marked and labded/placarded,and aro in all respects in proper cortdltiorr for te are fully and acco{ataly described above by the proper shipping name,arrf ora classified,packaged, <br /> E90 tar,I certify that the contents of tfds 4 to a natkxrat gavemmentat raguladons.It expoR shipment and!am the Primary <br /> carsfQncnant canfonn to the terms of the attached EPAAta <br /> I cart4fy tlxat the waskrrdnimlzaEbn statement Warded In 40 CFR 282.27(a){if I am a large 9� tY 9aneramr}or ) yl �9�4 true. <br /> Generator e P' ypad Na { ; IL r <br /> � i6.Intematcn�shdpmenLs `. <br /> Transporter signature for ❑Import to U.S, ©Export tram U.S. J Port of entrylexk: <br /> { exports only}: <br /> 17 Transporterrx,�t of iiee ept o<Ma�ada[s Date leaving U.S.: <br /> 7ransparterT Fd S"ture <br /> Q coraco rter2 Pnrtted/Ty, Name t <br /> 18.DLscrepancy <br /> k <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Typo ❑Residue ❑Partial Re}dw ❑F0 Rejection <br /> ifib Altamate Fa'4(�r C,rnerator) ManifastReference Numixr. <br /> U.S EPA ID Number <br /> V <br /> I- FacTdy'sPhore: <br /> 0 12—S' atureof Attemate FaaZity{or Generator <br /> i Month Day Year <br /> 19 Hazardous Waste Repax Management Method Codes{.e.,codes for hazardous waste treatment <br /> We 1, 2 deposal and mcydaV systems,. <br /> 3 4 <br /> 20.Designated Faclity Owner or OPer&r-Ceffmation of receipt of hazardous materials armed by the manifest a <br /> cin_ yped Named m them 18a <br /> 5ignatura tont Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. <br /> TRANSPORTER'S COPY <br />