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Please print or type.(Form designed for use on elite{11p:j typewriter) <br /> UNIFORM FlAZARDOUS 1•Gen tartar lo� 2 Page i of 3 Emergency Response Phone q Fawg7 �6d.41.+�No. 3g. <br /> WASTE MANIFEST'- x " O r 640 JJ K <br /> 511ra s i(ame rind M2 Iing Address <br /> Ef i r rJ Genal es Sb"nm ff216.9,14 z <br /> 4Rt a1 �^�a;;: address, <br /> C,an@rat5es Phone,- <br /> 7 <br /> hone_7 rraIar&paier 2 Company Name <br /> U.S,EPAIUNumber f _ <br /> k�'IS cifDt <br /> eye Ld��IF s <br /> o Cr33 07 <br /> FadlrysPhone e z3 fr LGoU�Sras" <br /> e. <br /> 9a. 9b U.S DOT CescipbDn CnAK5er9 proper 5nprirg Name,Hazard Clam,ID Nmjw,, 10 Contauiers <br /> HM and Paeking Group Of any)) _ 11 Total 12 Unit 13 Waste Lcd�s <br /> 1 +may, r r r r.a�,.� .x �� _r.r= ti ti ti a Kyr, of i1. ._n N0. Type a�Ely WLAId. <br /> O <br /> �0 <br /> z 2. <br /> 3 -- <br /> 4. <br /> r <br /> 14.IMLW kyr ; arrd Addltionai Intarrnatlon <br /> 15- GENERATpR'gIpFFEROR'S CERifF1CATI0N:f <br /> marked and labeled! h Y deck"Roam rzrrter>!s of this corxignmentarefugy aixl accrria <br /> placarded,end are in aA respects in proper corm r&n for s desaibed above by ifra proper s OW9 name,aid are asset packaged. <br /> Exporter,I certify that the(onteFlta Of this consgrrmeat conform to Me(LlTn3 of the ettadred PA a j Cansenl 0—mvntaf repbtions if export erg and f am Ih@'F LTar. <br /> 1 ce!fxythat the waste mk imtzatien statement kknftd In 4 CER 262Z.'g){it I am a targe quanhtY or �f!lamas Cienerator'sfORerars Pr3ntedlfyped �. .(b)� lY generatQrl is true. <br /> -� 16.lntemational Srripmenty <br /> x T LJlmpm to U.s. L <br /> ransporter sigrratum(for exports onfyl: 'U•S" Part of errhylexiC <br /> 17.TrAnVorter OfRem*ofMaterials leaft US- <br /> I <br /> S1 Phnted/iyp@dry V <br /> L1 l <br /> jr, Monthfro r2PdntedlTypedName X iYe <br /> LL J t' <br /> 4+• � th `Day Ye <br /> 18.Discrepancy <br /> 18a.Discrepancy lndiption space ❑ Quantity . <br /> ❑Type ❑Residue ❑PIU Rejer#ion <br /> ❑F,°Rejection <br /> 18b.ANemate FapTity{ar Generator) Refereaca Number. <br /> Q U.s.EPA ID Number <br /> U- Facility's Phone: <br /> Im <br /> LIA I k Signature of. Fatuity to Generator) <br /> Month gay Year <br /> C7 13.HazardousWaste Report Management Mgtfiad Codes Codas far hazardous C waste treatreeat I and re 1• � cyGing systems) <br /> 3. 4 <br /> 20.Designated Faality Owner or Operator:C@r♦ilkayon of <br /> nom,:yPed Name re fit of hazardaris materials covered by the rnafflIt0a t G as noted In flim Ioa <br /> •Vti✓r <br /> V<xth Day Year <br /> EPA Form$700-22{Rev.3-05) Previous edfbons era obsolete. <br /> TRANSPORTER'S COPY <br />