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Mase-Tint or (Form des ned for iM on elite(12_:.Ch)typewriter.) <br /> UNIFORM HAZARQOUS 1.Ge erafar ID Number Farm Approved.Q B(42059.0039 <br /> 2 Page 1 of 3 Emergency Response phone 4 Maniteat Tracking Number <br /> WASTE MANIFEST <br /> and ®�5 8 6 4 6 7 JJ K, <br /> 5.Gen.era0o�� lame Mali�ng Address <br /> [3�L3 Ganr3ratar's Site Address(dd;fferent than mat'ng addn:ss� <br /> Generator's Phone:' <br /> 6.Transporter 1 Company Name <br /> i 4, u':+' U.SEPA—Null 1=r <br /> 7.Transporter 2 Compa4 Nam; + <br /> U.S EFA ID Number <br /> 8.Designated aCRity)Vame arId Sit�Add ss' <br /> tdCN.�JY� <br /> 1aoC!t::. 6�t#.fi';�J.r•�3tn i.tt . <br /> Fadrtys Phoria:,,-Fi5 j156 <br /> 9a. . 9b.U.S.DOT Description(atduding Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Pacldng Group Many)) 10 Containers 11 Total 12.Unit <br /> T <br /> 1. ype Quantity WI.NaI <br /> No, 13 Waste CodesC. <br /> { ;'.":l?' ''=f+�f4s'}C'r: •r �jw � '.!� kl!� c`]Cf112r,�-�'i 1• <br /> 2. <br /> LU <br /> 14 Speciai Handling Instnrcttons and A ditional Inform bM <br /> i <br /> 2 5-3 ' <br /> r <br /> r <br /> 15. GENERATOR'SlOFFEROR'S CERTiFICATfON: I leby dedare Thal the are in acontents otth's consignment are Tully and accurately described above by the proper shipp!ng me,and ere dassKed,packaged, <br /> marked and 1abeledlplacarded,aitd lly n Proper cord tlon for transport according to applicabie Inlemat! I d national gove.T ,ental regulations,If ex rtshipment and i am th;Primary <br /> Exporter,I oertity that the contents cf Niis consignmen to the terms of the attached EPAAcknowl <br /> 1 Ce"that the waste '- tion"statement iden CFR 262.27(x)(if I am a large quantity edgment of Cpp'ns <br /> slOffejx'a PrkttedlT dky Na r9 4 ry generator)or{b)j!f l am small quantity erabr)Is true. <br /> � ignatu <br /> .. f Ybar <br /> ntemMISational5tupments z r <br /> I .5. <br /> Transporterslgnature(for,exports only): ❑Export from U.S. of entry/exit � <br /> 17.TrartsperEerAdupNdedgrrrent ofRaoeiPt�Materia'', a leaving U.S.: <br /> Ce ransperter 1 nbvy yped Name ti + <br /> Sig F1 r Mo Da Year <br /> Q Transporter2PrintedlTypedrxame ��� ! 4Z, lY/�� j� L <br /> Y <br /> . ' , <br /> i"" � <br /> S Faeafe ,r <br /> Month Day Year <br /> 18,Disrsepancy <br /> 18a.Discrepancy Ind cation Spate LJ ❑ <br /> Quantity Type <br /> LJ Residue ❑Partial Rehr t i <br /> ❑Fu,Re etU.r <br /> 18b.Ahmate Faciiity'or Generator) Man fest Reference Number. <br /> U S.EPA fD Number <br /> Faci ity's Phone: <br /> 18c.Signature ofAltemats FadRty'ar Generator) <br /> a <br /> Z Month Day Year <br /> y19.Hazardous Waste Report Management hfetltod Codes 0.0,codas for hazardois waste treatmeri dlsposat,and re <br /> ryytiing systems) <br /> ]. J� <br /> Z 3 4 <br /> 20_Designated Fadrity Dwner or Operator.CeOfeation of receipt of hazaro=mate,a s covered oy the manifest except as nded in faro 169 <br /> ame r r <br /> ;PA Form 8700-22{Rev.3 05) Previous editions and a6so�eta �: <br /> TRANSPORTER'S COPY <br />