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a Form Approved.OMB No.2050.0039 <br /> Please print or type. a.ManlfQat Tracking Number <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone �„ a aJJK <br /> UNIFORM HAZARDOUS Y <br /> WASTE MANIFEST X, Generators Sita, reesf(if different than mailingaddress) <br /> 5.Generator's Name and Mailing Address ( ,i yt.� q f a ar•-�ej•- ,kliml <br /> enerat es Phone: <br /> ' ,. U.S.EPAID u ber ��, ""7 <br /> 6.Transp`o r 1 CompanyiNatme,r; �, y ��;'., '' "tom I e <br /> U EPAID Number . y <br /> 7. ra sporter 2 Company Nam9. .w ) (� �( I•-6-;)�.J G;� •�7 f� }!�% 2{ <br /> �.' ` ' r {t U.S..EPA ID Number f <br /> 8.Designated.FacilltyName and SlteAddress py �� <br /> qAsY <br /> Tacility's Phone: 10,Containers 11.Total 12,Unit .13.Waste Codes <br /> 9a 9b.U.S;D0�'f)e'sdriplion'(Idciuding Proper Shipping Name Hazatd Classy ID Number, Not Type Quantity Wt.Noi. <br /> HM and Packing Group(if any)) ".�t`r" N <br /> 641 <br /> °4 NtJ.evr <br /> Z 2• <br /> W <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and A f <br /> dditlonal Information �^ <br /> by the proper <br /> ng name, <br /> are <br /> 15. GENERATOR'SIOFFEl20R' �tly described bow <br /> SCERTIFICATION I hereby declare that the contanstsoo this <br /> consignment <br /> aapplicable liy and aucun A nternationet and national governmental regulations,iI Pexport shipment and I,am�lire Primary packaged, <br /> marked'and Iabeledlq�acatded,'and ate`In all respects In proper condition for transport <br /> Exporler,'i certify that the contepts of this.co1lslgnmerit conform to ihe'terms of the attached EPAAcknowletlgmentof Consent, py Year <br /> I cedi(y,lnal the v+asi'e.minimization statement Identified in 40 CFR 26227(a)(if I am a taiga quantity Signage or(b)(if I am a small quantity generator)is true. M n,. <br /> �• �.? <br /> Generalorsl0 et'?sPrintedfT ped Name <br /> Al <br /> 16.Internal al Shipments Q Export from U.S. Port of entry/exit: <br /> El Import to U.S. Date leaving U,S:: <br /> Transporter,signature(forexports only): <br /> r* <br /> 1ZTranspoder Acknowledgment of Receipt of Matedais Signature 1 ,+ M nEth /Day Year <br /> LLI <br /> Transporter 1 P tedrryp d Name <br /> t-'k V/� ) r,a f / Month Day Yea` <br /> a Signature > 1 �t'rt r 4 .r <br /> z T nrrter 2 PrIn))ted/Typed Name jt 7 J ra f ?, a�! "{� 015 <br /> 18,Discrepancy ❑Full Re action <br /> Type <br /> ❑Residue ❑Partial ReJection 1 <br /> 18a.Discrepancy Indication Space Q Quantity <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> I, 18b.Alternate Facility(or Generator) i <br /> m <br /> Facility's Phone: �.. . � ;. , ' <br /> Mo h Day Year <br /> IW 18c.Signature of Alternate Facility(or Generator) <br /> 4 <br /> Z <br /> 19.Hazardous Waste Report Management tvlelhod Codes(I e.,codes'for hazardous waste treatment;disp3sal an re6y <br /> cling systems). 4 <br /> 20.Designated Facility Owner or Operator:'Certifroatlon of rebelpt'bfhazardbus:materials covered,by the manifes6xceovas`ncted In Item't88 Month Day Year <br /> Signature <br /> PrintedfTyped Name <br /> TRANSPORTER COF <br /> jEPA Form 8700-22 6v.12-17) Previous editions are obsolete. <br /> I <br />