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e8se print or We.(Farm designed for use an elite(12-pl`i hl /pewrfter) Form Approved,OMIl3 No.2054-0039 <br /> UNIFORM HAZARDOUS 1 Generator lD Humber,.-, 2.Pa e t of 3.Emergency Res ne .' 4,M Response Ptwest Trar <br /> WASTE MANIFEST g .11612T8584 J J K <br /> 5.Generators Name and Mairn Address s Generatgrs-SdeALdd1ss.T afc fa4 a.,ng aade") <br /> Generators Phone: <br /> 6,Transportef 1�Cpmpany.Nay US EPA D,Nuprb¢c i <br /> 7.1 porter 2 Company Name ff U.S.-EPA 10 Number- <br /> i d! t � .sir ( � �" l�� �c�•�� r~' �� ' � � '� -t i� j F� � C.✓�� ��.- f ��✓ �"� C.. <br /> B.,A ignated.EacMryNhme.and Site Address U.5�AIDNumber <br /> / gJ307 <br /> Faciltt/s Phone _ .• (66 1) �'�.e7:�'�.�5� t�L�.!`��t�� J �� <br /> 93. w US Doi Deskxiption(mduRtrg Proper Shipping Name Hazard Clam,ID NumbW, 10.Containers 11.Total 12.Unit 13,Waste Codas <br /> }{M and Pack ng Group(darty)) No. Type Ouantity WL/Voi. <br /> Z 2LLJ <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Fiafi Luuctions and Adddional Mformatian. r yy <br /> j rl4 r Z(GyuC, f31. <br /> f/' ' <br /> 15. GENERATOR'5fOFFEROR'S CERTIFICATION:i t tere dedaro that the contents of thfs,conslgnment are fusty and accurately described above by the proper shipping name•and are dasslfied,packaged, <br /> marked and kxrded,and aro In all respesn proper cdndidw for transport ao'b6 d 6g to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Exporterrl certify that the contends of the canslprana knnfkirm to the terms of ffie attached EPAAconowfedgmenl of Consent <br /> I certify that the was_3e r,rftnIzat9 statement identified in 40 CFO 262.27(a)(if I am a large quantity generator)or(b)(ff t am a small gdantEty generator)is true. <br /> Generatorsl0ftmra tec ryped Name'A `�g Signature htg D y eat.7 <br /> t '.' <br /> ...I 16.Intematlonat Shipments l r .� f <br /> F ❑Import to U S. ❑Export from U.S. Z ort entrylexlt <br /> Transporter signature(farexpDrtsontyl:: _ laavjpQ .5: <br /> 17.Transpo6rA*vNl dgment of Receipt of Materials ,f , f <br /> Transposer 1 PrintetlfT }{K �.. Sign re * Mone y <br /> Co <br /> Transporoer 2 PriptedlTyped Name• Y { r_ Sgnature t4 t0.8YY Ye <br /> 10.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ CK-fity i ❑Type ❑Residue ❑Partial Rejection ❑Fut Rejection <br /> Menlfest Reference Number. <br /> 18b.A@emate Facility(or Generator) U.S.EPA ID Number <br /> V ' <br /> Lr Facitys Phone: <br /> 1 Bc.Signature of Alternate Facility(or Generator) .► Month Day Year <br /> ► f <br /> 19.Hazardous Waste Report Management Method Codes Q.e„codes for hazardous waste treatment,dlsposal,and redydtng systems) <br /> t� 1• 2. 3. 4, <br /> 20.Designated Facility owner or operator.Cerliflratrori ref receipt bf hazardous matsrlais covered by the manifest except as now In hem lea <br /> rinse yped Name Signature Month Day ear <br /> EPA Form 8700-22(Rev 3-031 Prev ous editlons are obsolete. TRANSPORTER'S COPT( <br />