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C <br /> Please print OFW.(Form designed for use on elite(121itch) ser.) ' <br /> UNIFORM HAZARDOUS, 1•GenesatarlgNwn , FormAp}�roved,OhNo.205W39 <br /> 2.8aae e <br /> t of 3. _. Rf <br /> WA5TEMANIFEST <br /> ,,or?P`�one +M.lri�a7q�lr -89 <br /> J a/ <br /> Q �� <br /> 5. r nd Ma%g Address <br /> ��� Generdfo�SSite rCmtd{erenttharrmar3nga } <br /> Generator's Phone: <br /> G.Zratrspoiter.griComp9rip Na <br /> Nm II r £y U.S. <br /> a <br /> 1 t (` i '�•d r" (� �`\ '� I��-- r.. - U�i�1D Number �, <br /> --------------------- <br /> 8.Deaf-id�ad arid'Site7Ctldre�' - <br /> 1L+ SAI-, nl� <br /> FadGtys Phone: <br /> r <br /> 9a. 9b.U.S.DOT Dasaipt`�Cffx xfag Proper Shipping Name,Hazard Class,ID Number, 1 tamers <br /> HM and Pac>cl-�Gawp(rf anyy)) 11.Total 12.Unit <br /> r.rr,Re r <br /> 1 No Type Quantity' WLAbl. 13.Waste Codes <br /> r <br /> 2,Uj - <br /> 3. <br /> 4 <br /> 14.SpegahH t19n9]rmstnr 0-and murbanai information <br /> S, <br /> Dd,157 Kt37'.Irl <br /> 15 GENERATOR'SJOFFEROR'S CERTIFICATI6N:i hereby declare ffmat rhe r of this consiypanenl are fogy and auuratety desalted above by the proper sh <br /> radiad and Iabeledlpiamow,and ata in ON m p its in prt W cordon for tit Mu ft to ippcg name,art are dasslhed.packaged, <br /> F.xpOrker,I oerdty that the contents of oris cansignmeM=ifnrm to the teres of file attached aPi+��t>ae mt of Uenat and national gaverrunentai regm+lats Jf evort shipment and tam the Primary <br /> I certify that the waste minimization statement identified In 40 CFR 26227(a) rf I am a jMt � <br /> Generator'slORer ytt �e r {) Q TY g rata)or(b;.41 am a small Quan y generatoo Iz true <br /> ! • . �,, ignaltire <br /> th ! <br /> 16.Intematdonai Shipments { l <br /> x Transporter signature for ❑import m U.S ❑Export 6mm U Pat of entryfexit <br /> { expods Only): � � I � <br /> 17 Transponer Gmowfedgment of R"l-Materials Date U.S <br /> � Transporter 1 - ' <br /> C) <br /> Q raps .r2Prg <br /> � r Name —7 l ✓ <br /> 1 Suers <br /> 18.Discrepancy <br /> 18a.DIscrepa,cy-rdiption Space 4' <br /> ❑ Quantity Type ❑Residue ❑Partial Rmsecw ❑�tL Rajmk'Jsr <br /> 18b Aftemate Face,-.{a Generamri Manifest Reference Number: <br /> U.S.EPA iD Number <br /> Facm-vs Phone <br /> 1&.Si natumoffvtem_F.a,Iy arGenerator) <br /> z Month Day Year <br /> i 9 Hazardous Waste Report Management Method Codes(e.codes for hazardous waste treatment,disposal,and nrcyr3"mg systems} <br /> 1 <br /> 4 2 3. <br /> 4. <br /> 20.Designated Fac Owner or Operator Certification of receipt of hazardous materials covered by the manifest <br /> Frtn edlfyped Name except as ncled in Rem 18a <br /> Signature <br /> Month ay Year <br /> EPA Farm 8700-22;R4V 9-45) Prev ous editions are obsolete <br /> TRANSPORTER'S COPY <br />