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Form Approved OMB No.2050,0039 <br /> iDiase print or type.(Form designed for use on elite(12 typewriter. 4.Manifest king Number <br /> pricy Phone <br /> 3 n <br /> 2,Page I of 3.Emelp <br /> I.GeneratorlD Number 0 SKS <br /> -aRDOUS <br /> UNIKIRM'AA <br /> WASTE MANIFEST <br /> 5.Generators Name and Wring Address <br /> yo <br /> I s Generator's Phone' � • ' U.S.EPA ID Number <br /> 6 Transporter I CorMany.Namo <br /> 'o <br /> UA F-PA 0 Number <br /> 7.-ra—mgponter2 CornpenY Name <br /> EPA ID Number8,Designated Facility I;E;rne and Site,Address <br /> 4G ROL.T <br /> Faoili s Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Sho*Q Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. t Type Quantity WLNol. <br /> 0 <br /> — <br /> E4, T <br /> 14,Speciai Handling Instructions and Additional Information v 4 <br /> 15. GENERATORVOFFEROFUS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are irfall respects in proper condition for transport a=rdinq to applicable international and national governmental reViulattions.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment <br /> gnment conform to the terms of the attached&A.Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262,27(a)CO I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offeroes Printedrryped Name S-Vature Month Day Year <br /> 16.Intemabonal'Shipments; <br /> 0 Import to U.S. Export from U.S. Port of entry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w17 Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrinhWTyped Name Signature, Month Day Year <br /> OL <br /> TraP.sporJer2PfinW0ypedName Signature E Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity D Type ❑Residue 71 Patii Rejiectio, ❑Full Rejection <br /> Manliest Reference Number: <br /> U.S.EPA ID Number <br /> LL Facility's Phone. <br /> M <br /> LLI 18c-Signature ofAftennat a Facility(or Generator) Month Day Year <br /> 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> Ul <br /> C3 <br /> 2Q.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as nclad in tharn 182 <br /> Primad/Typed Name signature Month Day Year <br /> EPA Fo,rm 8700-22 tFwv,3705.1,Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />