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z r <br /> P <br /> Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1"Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.14tanlfesE T3486212 <br /> racking®®Number <br /> WASTE MANIFEST. "C,A' L 0 0 0 3� 4 0 a 6 1 f 000 024-0130 U� 3 4 0 6 2 1 2 JJ <br /> 5.Generator's ame and MailingAddress �� qtl- $ 11 ,i)s�()RES. Generator's Site Address(if different than mailing address) <br /> SMEL <br /> 2..324JAXVN-'bR1VE,::. <br /> 8T0Q-KT01 T:;CA,06200.._ <br /> Generator's Phone;:..'2: :0;:,.. ,. 5.,4 ..5:r. 1 '.Q..1,.1 . <br /> 6.Transporter 1 Company Name U.S,EPA ID Number <br /> PATRISERVICES �' C A D a 5r <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desi a'ed Faclll Name and Site Address U.S,EPA ID Number <br /> o 1�M t -DILL. -KHF-. <br /> .35251-OD;9KYWNE_ROAD.,' <br /> t4 LEMA[q GA.,032 ' <br /> ," <br /> Facility's Phone:. <br /> C. A-T..0.0 0 6. 4 0 1 1 7 <br /> ga" 96.U.$:SOT I]escription(iricladirig Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(f any)) No. Type Quantity Wt./Vol. <br /> ;VON-RCRA.HAZARDOUS. STT.90L DS.(9R0...Wq DUST,. 419+ 501 <br /> . COPPER) <br /> 0 -0 1 CM 00020. Y <br /> 2. <br /> LU <br /> c� <br /> 3. <br /> i. <br /> 4. <br /> a <br /> 9 <br /> 14.Special Handling Instructions and Additional Information I)GA01045 <br /> Affrays wear approptiate PPE when handling waste.JCB# 09-19-00078 1 <br /> 15. GENERATOWSIOFFEROWS CERTIFICATION: I hereby declare that the contents of this eonstgumant ardfulik and aocuratety descrjbed-abovd'by the,ptoper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are In all respects In proper condition for transport according to applicable internatlonaland naUvnal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minlmiz4on statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratveslOfferorsPri ledrry ed Name ! Ao ez� Sal Month Day Year <br /> a <br /> _j 16.International Shipments <br /> t- ❑import to U.S" ❑Export from U.S. Port of entryroxit: <br /> 2tTransporter signature(for exports only): Date leaving U.S.: <br /> w 17,TransporleOcknowledgment of Receipt of Materials <br /> T€ansport rinledlTyped Signature Month Day Year <br /> � <br /> /moi " <br /> 0 <br /> QTransp ;ter 2 Printedlryped Name Sig re Mo 1h Day YeAr <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑Type ❑Residua ❑Partial`Rejeation ❑Fut Rejection <br /> a <br /> 1 <br /> Manifest Reference Number. ' <br /> 18b.Atternate Facility(or Generator) U.S.EPA ID Number <br /> tJ <br /> Facility's Phone: !. <br /> w 18P.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19,Hazardous Waste Report Management Method Codes(Le,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI <br /> � 1 2. 3. 4. I( <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> PrintedlTy ed dame SipMonth Day Year <br /> Grb� �1 2+ <br /> EPA Form 8700-22(Rev.3-05) Previous a Itio are obsolete. D r-!sIa1v1/AT Ven n imm rnmurxi snur(ir- EQUERE ) <br /> il <br />