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Pip ase rint or Fo desi —d for use on elite (12 -pitch) typewriter.) <br />Fnrm Annmved. OMB No. 2050-0039 <br />tYPe• <br />P , ( � 9 <br />generator ID Number 2. Page 1 of 3. EmergencyResponsePhone 4. Manifest Trackieng Numbe <br />UNIFORM HAZARDOUS [1. <br />trat�*�,€1 t <br />j•`'" <br />WASTE MANIFEST.i<, re,,,F �.w ,� e'a d : <br />5.Generator's Name and Mailing Addressj$;:{r,;,„ Flat'" Generators Site Address (if different than mailing address) <br />sX <br />Generator's Phone ✓ n <br />U.S. EPA ID Number <br />I <br />6. Transportg� I Company N am A r <br />g <br />p r � m 1 <br />Vz,r` ze�.m 4..»li fs F o-"6..$% tt., �»� �nm98 s { ...,`l.td, <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address ) ""' U.S: EPA ID Number <br />9 ty a..d i *s.r ti t, r40 <br />Facility's Phone: &10 -i 95 —14!503 <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />O <br />4.4e <br />`eye <" .,s;✓ � t'r 4`,j ? � ; c%:r' � <br />... <br />t ` <br />2 <br />Uj <br />t <br />3. <br />�� <br />*` <br />8 � � <br />V w <br />�' <br />, • <br />l '°; P not , O F s .r° ..? ,i`.t� f � *," •, FSF C✓r+R<� . � <br />j3 � <br />4. <br />. .w <br />14 Special Handling �'s, ctions and Additional Information /a_ <br />far is r. —;7/ <br />15. GENERATORVOFFEROR'S 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 in all respects in proper condition for transport according to applicable international and national 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 minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b)fif I am a small quantity generator) is true. <br />GeneratorslOffgroe-s,Pnntedflyped Nano Signatures <� Month Day Year <br />J <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: _ <br />LU <br />17. TransporterAcknowledgment of Receipt of Materials <br />Transporter 1 Print drryped Name Signature Month Day Year <br />QTransporter <br />2 Printedrryped Name Signature Month Day Year <br />tY <br />H <br />16. Discrepancy <br />18a. Discrepancy Indication Space ❑Quantity ElType ElResidue ❑ Partial Rejection ❑Full Rejection <br />--- - - Manifest Reference Number: <br />18b. Alternate Facility (or Generator), ,.. - U.S. EPA ID Number <br />J <br />V <br />„ <br />LL. <br />Facility's Phone: <br />� <br />18c. Signature ofAltemate Facility (or Generator) <br />Month Day Year <br />Q <br />z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />( <br />! f <br />t f <br />a <br />1 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedlTyped Name Signature Month Day Year <br />orf I <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />