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Please print or type (Farm designed for use on elite(12-p€tch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number C� _ �~ 72Page 1 of 3 Eme a Res�°rsfsa Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L �� V ..� r C 6r) '!'7 w--S11 <br /> 5. tors Name and I4at<ing Address �- 4 JJ K <br /> 6'era�!14WP. Generators Site Address{if different than ma;tng a{dress) <br /> 1 IZ•t)I W. 4!h"* �+ F-�1 <br /> 5Mq 1 . 9y <br /> Generators Phone <br /> 6.iransporier.l Company Name <br /> _°'ge VV-d Vw',InU.S.EPA i0 Number <br /> 7 Transporter 2 Company Name U.S.EPA Ip Number <br /> 8.Desig€tated:Facity Name}yut.5ite Address( r U.S.EPAIp Number <br /> tE ]E. �4t if ti7s.f?1=s r <br /> Facitity's Phone: <br /> 9a, gb.U.S.OOT Description(including Proper Shfpp'vg Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group('darty)) ]7.Tafel 12.Unit 13 Waste Codes <br /> 1. =:,:R,-r.A 111-MR001J1- t ,:: , Na. Type DuanS'ty W1Nol. <br /> Z 12. <br /> w <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special HandlInstnxtions and Additional Informatics <br /> q <br /> Lt t3L �+ n <br /> 15. GENF_RATOR'SIDFFERORIS CERTIFICATION; I hereby declare that the contents of this consignment are fuly,and accurately described above by the proper shipping name,and are lass[red,packaged, <br /> marked and labeledlplacarded,and are in all raspeds In proper condtiion for transport according to applicable Intemational and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I eertity that the contents of this consignment conform to the terms of the attached EPAAcknawledgment of Consent. <br /> I certify that the waste minimizatlan statement identified in 40 CFR 262.27(x)(B I am a large quantity geneptor)or(b)(d I am a small qua4ty generator)is true. <br /> Ge _ Offerors-Aln <br /> erryped Name nature Uvk.' VM Mo Dayy Year <br /> =� 16.imemational 5hlpments /- �A " I <br /> ' IMP04 to U'S. ❑Export from U.S. Port of en le' <br /> �. Transporter signature(for exports on <br /> �)' Date leaving U.S.: <br /> O17 Transporter Admowl rnent of Receipt of MaterialIZ—s —��` <br /> Transporter 1 Print_ yped erne � 5ignabr� <br /> X111 4 '511'Jl ----- c' / S f� <br /> aMDA Day, Year <br /> TranspaRer 2 Pnntedlfyped N me <br /> C Stgnabs Month Day Year <br /> 1B Discrepancy <br /> 18a Discrepancy Indication Spate <br /> ❑ Ouantty ❑Type ❑Residue ❑Partial Rejedfon ❑ O Re{ecllon <br /> 1 Bb Alternate Facility(or Generator) Manifest fleference Number. <br /> US EPA ID Number <br /> w <br /> LL Faplity's Phone: <br /> 1 Bc,-JlnaaJre of Alternate Faality(or Generates) <br /> Q Month Day Year <br /> g.Hazardous Waste ReportManagement Method Codes(i.e.,codes for hazardous waste treatment disposal.and recycling systemsl <br /> C t, H )" / 2. 3 4 <br /> ti. <br /> 20 Designated FaaTty Ovmer or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item i Ba <br /> printedlTym flame <br /> L ( J� r- r Signature --�/ — Month Day Year <br /> EPA Farm 8700-22(Rev.3-05) Previous ediSons are obsolete <br /> TRANSPORTER'S COPY <br />