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Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved-OMS No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generebr IQ Number 2.Pega 1 ul 3.Emerpenr:y Resnor....Phone a.Manifest Tracking Number <br /> WASFE MAN IFE$T S K S <br /> 5 Genera lots Name artd Mailing Astlress GeneraSOYs Site Atltlrfass{if different rnan mar[rng apprvss) <br /> f�enarator's Phone. <br /> 6 rranvportrs t Company Narme U.S.CPA IU IN— <br /> b-7 Tmnsperiar2Company Name LIS EPA fo Nvmbar <br /> 9.beaig.,Wd Facility Name and Srte Address _ u.s_a=PA In Nnmhvr <br /> r <br /> racJitY's Pitons: <br /> qty, yl�.U S.DOT Description(including Proper SIName,H—Cl—In N—, SO.Containers 11 Taml t2.Unit y.W—'.nupva <br /> antl PacklnS Group(If anyll <br /> N. Typc Qaanrly WI.N I. t <br /> d <br /> 2. <br /> ca <br /> a,Sp—I HandII Ins--r—AddiLnnal Fnrnrmatk,n -f•:?;.. - <br /> 4:fmR5*17,1 <br /> FdR -aIP Pr1_j.�� <br /> ib GENERATOR'SIOFFERaR'S CERTIFICATION: I hereby declare that 14.v contents vT Ihls cvnsignmanS are Nlly and accurately tlesrsibatl above by—M1 proper snipping names,atn are classitlep,pa vkxged, <br /> arkr<d antl lalfnir>rlI{rlxr:xslxd,and a all respects in proper anpiu yr transport accortliny Ic auuliu Wa irrtxnmtinnal and natinnnl gnvemmanml-.90.t—If e><tlpttslNpment antl t am the F nmary <br /> E <br /> the oser, cethrtify that te mm[ants or fnis consignment cpnlarm[a the terms of Ilia alFacPad EPA Ar:Pnawledgment p ConseXnt. - <br /> ly rhar n wasminimi?atinn r.Iap,mcnl ipr mlihad in M CFR 262.27(.)(i£i em a large qua mlty genera...nr to;(.1 mail quamily goncratvrl rs trvu. <br /> Generato!'s/Oflerofs Pnnmp,'fypvd Nam¢ Siyrraivra vn[h [Jay Year <br /> t6 Inhrrnauanal sninmen's �_�lrr�t rn u s _ <br /> Q Export from u.s. Port or enrryli:.ir <br /> ture(tor —'evparts pnfY7: Dleaving US <br /> 17.T�ne�p-naAr*rxiwletlgmen:of Receipt of Malerisls <br /> Transpartcr 1 PrinludfTyuud N.nna Signalura Monthr <br /> nay Y.. <br /> w <br /> � Tranapadar 2 PnntetllTypau Nan'ia Signarury MPrt[h [Jay Year <br /> T 15 Disn�r[arePpnncy <br /> tea.n ncY lndieatlen,s[w.nx � Quanbry � 1 T— rr�� <br /> U Resdpua �Partial Re/aclron �Full Rejection <br /> Manifest Reference Number' <br /> tab_AMamaee>=acil}ty(p.Generator) U.S.EPA ID Numtaar <br /> s4i i-acillty's Phone; <br /> G c. ,g—t a vt Arternate Faeiidy(pr Generalrn Month Day Year <br /> 4 <br /> 1 B.Hazardous Waste Ra—rr Manayvrnrn.l Mcr I Cody.0 v mops far hazardous waste tcaatmeni.disposal,and recytlin.systems) <br /> 0 1. ' 2. 4, <br /> 20.oesignstpp Fa Tglly ri7yr *'op..—: <br /> Certificaban of recalpt of M1azardous matedats mverad by Ihu mar�h. ,e�.vyl.......m Item tga r <br /> 111 [ed/ <br /> nnType Mai— bay <br /> J _ _ <br /> EPA Form 8700-22(Fxev-3-05) Previous edltlons are obsolete. �,=�1r l�etl.TE 'CILI'fY TO GEINIERPOM Fl <br />