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Please pfjnt or"type.{Form&jgned for use on elite(12-pjtch)typewriter,} 'Forfra A,.ProvdOMS No.2050-D039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE ItWHIFIwST 0.14783164 JJ K <br /> 5 Generators Name and trtaifng Address ' Site 4ddress{dddferent than ma�ng address) Y <br /> Genera l P e �t�i r ') /pr Vie) <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> wiry ?, t_ td <br /> T.Transporter 2 Company Name U.S.EPA ID Number <br /> a.Designated FaaSly Name and Sita Address.VeftU.S,EPA ID Number <br /> 1629, <br /> FaaXY5 Phone: ___GZ11k <br /> 9a. 9b.U.S.DOT Oescrip8on{crdudir g properShippirg Name,Hazard Class,ID Number, 10.Containers <br /> HM da <br /> and Pang Group{rf any)) 11.Total 12 Unit 13 Waste Codes <br /> _ No Type Quantity WtNoI. <br /> t1,' 1 `'ra':`���G:P,N t'L'^�.�1'���v'., +'a".�'-F _:i--�.. -ft_' •--1��.�r[CCr'TI - ' � <br /> O <br /> rZ <br /> Z. <br /> I <br /> 3 i <br /> 4 <br /> 14,Spacial Handling Instructions and Additional In tion <br /> 15. GENERATOR'SMFFEROWS CERTIFICATION:1 hereby;;dare plat the cont&t of this consignment are"and aearra desaibed above the <br /> marked and labaledfpfacarded,and are in all respects in proper condition for rt according fo by proper shipping If export <br /> name,and are d I am t d.Primer ed, <br /> Exporter,I certify that the contents of this ffthe at n9 � a fent Of con end netonai govemmerhtai regulations.If export shipment and I am the Primary <br /> consignment conform to the terms Dili;attached EPAAdoyovAedgment of Consent <br /> I Cal*that the waste minimization statement Identified in 40 CFR 262.27(a)(d 1 am a large quantity generator)or(b)(Il BIN small quantity generator)is true. <br /> GeADMI, <br /> Printed/Typed Name re Month Day Year <br /> lS P <br /> 16,Irdemational Shipments / <br /> I <br /> z ❑Impert to U.S. <br /> Transporter signature(for exports only): ❑Eh�O't Port of entrylexit <br /> w 17.TrargmrterA6TvMedgment of Receipt of Materials Dale ka�ng U.5_ <br /> jx Transporter 1 PrlrhtedlTyped N - <br /> C Sgna Month Day Year <br /> Q Transporter 2 Pnntedfryped Name r <br /> Month -Ddy Year <br /> 18.D=mpancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residua ❑Partial Rejection <br /> ❑F,,N Re,c�arh <br /> 18b.Alternate FaaTAy tar Generator) Manifest Reference Number <br /> -� U.S.EPA ID Number <br /> v <br /> Facility's Phone: <br /> 18a Signature of ANiemate Facflq ter Generaxn <br /> Q Month Day Year <br /> z <br /> y19.Hazer po Waste ReportManagement Method Codes;e,codes for hazardous waste treatment,deposal-and recycling syste <br /> Z msl <br /> 210.Designated Fme_Owner or Operator. <br /> rtteName... Certification of receipt of hazardous materials covered by the manifest except as noted in aero 18a <br /> dliyped Pp .� <br /> k l f �f`/} Signature r Month ay year <br /> EPA Form 8700.22(Revue-05) Previous editions are obsolete. <br /> '} TRANSPORTER'S COPY <br />