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Please print or type,(Farr-de64r"(Or;im an elite(t2j9:Jj)(yam_) Ftxmlipprtas+ed.O No. Sg' <br /> UNIFORM HAZARDOUS 1 Ge'' tD 2.Repo i or 3. Traskiny I tuber , <br /> WASTE MANIFEST JJK <br /> Gener2tots Name aro A1a,!rg Ab'�s; Grnra�'s Sha AMr=TA r tt,&-ieP.y addre j <br /> Generator's Phone <br /> 6.Transporter t Company Name u.S EPA ID Number <br /> 7 Transporter 2 Company Name U.5 EPA'D Number <br /> 8 Designated Fadity NameaW Stte Address U.S EPA IDNumber <br /> Fav;::: s Phone: <br /> ga I 5b U SDOT Oesarption('indudmg Proper Shipping Name Hazard Class,ID Number. 10 Con <br /> iamers <br /> HM and Packing Group Cd any)) No Type 1pwthy 112!Unit <br /> d 13 Waste Codes <br /> t 11 TOW <br /> z 2. <br /> Uj <br /> 3. <br /> 4. <br /> 14 Special Handing Insfruc5ons and Additional Information <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION:I hereby dedem that the contents of this consignment are Wand accum described above the <br /> marked and 3abeled(placarded,and are in a8 respects in proper coodtieo for ' by properquLaW shipping name,and are classified,I amt pardcaged, <br /> transport aocardorg 10 applicable ertemationaland national governmental regu{a6ons.H rt <br /> Exporter,a certify that the contents of this enj Idende conform to the terms of the attadred EPAAdmavledgment of Consent. t shipment and I am the Primary <br /> I testify that the waste minksdzaiion statement kkntlfied in 40 CFR 26W(a)(it 1 am a large quantity generator)or-(b){'AI arp a sma0 quantity ganetator))s.t!yd• <br /> Generates 11M printed�yp Name 5 yam <br /> � 16.Inb3mational Shipments <br /> x Transporters <br /> ElImportto U.S. ❑Export fromU.S Port of entrylexib <br /> ignaWre(for exports only): Date leaving U.5_ <br /> 17.Transport Admowledgment of Receipt of Mal enols <br /> Transporter 1 P' Name r'{ <br /> Signature #, �Uy ear <br /> Q ransporter 2 Printed/Typed Name 5 ! <br /> � - Month Day Year <br /> 18.Discrepancy <br /> 18a Discrepancy indip4on Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fu1 Rejection <br /> 186.A!temafe Facility(or Generator) Manifest Reference Number. <br /> U.S.EPA 10 Number <br /> V <br /> res. Facriitys Phare: <br /> me.Signature of Alternate Fadtity(or Generator) <br /> Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(e„codes for hazardous waste heahnent. <br /> w 1 dlsposa4 and recydmg systems) <br /> C <br /> it A..! I,, <br /> 4. <br /> 20.Dggtgnated FacI14 Owner or Operator.Certification of receipt cf hazardous matedais covered by the manifest <br /> PnntedR r excepjas noted in Item 1 Ba <br /> ,yped Name <br /> 5k)nature Month .Day Year <br /> EPA Form 8706-22(Rev.3-05) Previous editions are obsolete <br /> TRANSPORTER'S COPY <br />