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Please print or type,(Form designed for use on elite(12-pitch)ty)ewriter) Form Approved.Om-i No`.2D5 039 <br /> UNIFORM HAZARDOUS 1 Generator Ip Number 2.Pa�- Z-M,rlqlz- <br /> Emergency Response Phone 4.Manffest Tracking Number <br /> WASTE MANIFEST �} /{ r�r�5 Generator's Name a.d MaFirsgAddress itaAddress(if different than mailing address) -JJK <br /> Genera!oes Phone: r'151•+ .r- 1. �l� <br /> B.Transporter l Company Name a <br /> 'US EPA iD Number <br /> GEGrSge t 'wy ir-r. <br /> 7.Transpode 2 Company Name <br /> U.S EPA ID Number <br /> 8 Desg m�ated Family Name and Site Address L.S.EPA IQ Number <br /> if-:EREFtE.►,} 1T°�Fir ' <br /> 1 EiX E 13R3 Al 0j3E t ri FacaiMi sPhone: <br /> 9a 9b U.S.DOT Desc*1011(ndudng Proper Stappbrg game,Hazard Class.ID NL-t,-.rt0.Containers <br /> HM and Packug Group(if any 11.Total 12 Unit 13 Waste Codes <br /> No. Type Quantity WLPM. <br /> r— <br /> Ul <br /> z z <br /> c� <br /> 3 <br /> 4 FT I ........................ <br /> 14 Special Handling instructions and Additional Information +� y <br /> t-Sr$1171 <br /> fT r`t.1ILy ✓ 7 { 1) - <br /> 15. GENERATOR'SMFFEROR'S CERTIFICATION: I hereby declare that the contents of this crosign ment are fully and a described above the <br /> marked and tabeledlplacarded,and are'n 21 respects in proper condition for transport according to a accurately �' Proper shipping name,are are dassi h packaged, <br /> Exporter;I certify that the contents of this ricWedg errt of tiomaiand rsathtnal governrnerdat regulations.If export shipment and I am the Primary <br /> rbnsignment conform to the lama of the attached EPAAclmawledgment of <br /> I certify that the waste minimization statement Identified In 40 CF9 252.27(a)V i am a large quantity generator)or(b)(dj4rn aVw quarditygenerator)is tnre. <br /> Genera ffevrs Pdntedfiyed N�Ia <br /> -� /f 11 t 1/5� I-) � ' ff Month Day Year <br /> F 16.International Shipments l�L i l/(� v ❑ i + 3 y �f <br /> ❑ImportFart from U.S !�l5ort en exiC J� <br /> z Transporter signature(for exports any): U.S / � <br /> LW17.Transporter Adarowfedgment of Receipt of Materials Da atg U.S.: <br /> O Transporher�,P�inte�Syged Name <br /> Sgrtetnrte <br /> CL M" Day <br /> z Transporter 2 Phn'tedl ype5Zd Name Y� r 4 Y/f+' <br /> a Month Day Year <br /> � r <br /> piscrepancy <br /> 1 Ba.Qisaepancy Indication Space <br /> ❑ O""tity ❑Type ❑Residue ❑Partial Rejection ❑ <br /> Ful Rejection <br /> 1 Bb.Aftemate Faolfty(or Generator) Manifest Reference Number. <br /> =d U.S EPA IQ Number <br /> 0 <br /> res FacrT;tys Phone <br /> CI clic Signature OfAftema;eFacility(or Genemwr) <br /> z Month Day Year <br /> CIO19.Hazardous Waste Report Management Metfwd Codes(i.e.codes for hazardous waste hreahnent disposal.and recycling systems) <br /> LU <br /> t5 t 4 2• 3 <br /> r 4. <br /> 20.Designated Facilityl Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in ftem t Ba <br /> Printedffyped Name _/ <br /> s� J Signature <br /> Month Day Year <br /> EPA Form 8700-22(Rev 305) Previous editions are obsolete. <br /> TRANSPORTER'S COPY <br />