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Please print or type. ilFOrrn designed for use on(12- <br />' nil HAZARDOUS <br />WASTE MANIFEST <br />5.09,0_nei <br />s Nalrj_and Mailing <br />. Generator ID Number 2. Page 1 of <br />J... <br />'. ' <br />rorrn Approved. VMD <br />3. Emergency Response Phone <br />i... es k_.6.2y.jal_____________________alt_o <br />4. Manifest Tracking Number <br />0 15482457 %MK Address Generators Site Address (if different than mailing address) r: '•-•: )‘ Fr'e--151•14 <br />6,•TranspGeneratoottericompanyNarsphone. ..... - —67-1 <br />70 0 • W-,4-1‘ R4-1 r-enck 6 C. 9523! <br /> <br />1 iAn) A <br />U.S. EPA ID Number <br />iia, Ira porter 2 Company <br />ICSIRIICNIcW fl; 71' . m _ <br />8,2restgnateyi Facility Name and Set2AZ4ss <br />1'43 5 6 Y 110 ver C-; U.S. EPA ID Number <br />i _30 ld- /44-I, 54ree-i• geetch c,44 • cic 86 Facility't one' <br />• 2_-:.,5_.V.Y_S I i'0 9afillegevf 9a. <br />likt Sb. U.S. DOT Description (including Proper Shipping Name. Hazard Class. ID Number, <br />and Packing 10 Conta iners . 11 Total Codes <br /> 1Z Unit 13 Waste Group (if any)) No. Type Quantity WI Not . <br />17----R43—A 12-cM- 10124-L12o IFS, so i.r2> <br />col.Ly Jagsg-L--s ) €H 3 ,Dff 1950 I <br />. 35a <br />2. tve).4) Rc- OA- 14A244120105 :4) 45111 -,Q t..) r_sp <br /> <br />( Wet 5-4-e_ L‘.4›.-)i_t) ) <br />66/1 psi 145_ 4 <br />OZ3 <br />4. <br />I <br />1 <br />14 Special Handling Instructions and Additional Information <br />pV <br />. <br />eet Y Proper Pe-rSdiled ...7L1(-- 1 1- Pi- Mat <br />r ltt -1) i045G23 1?-1/ .2 )005,1R <br />15. GENERATO 'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fulki and accurately described above by the proper shipping name, ard 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 EPAAcknowleclgment of Consent. <br />I certify that the waste minimization slate ent identified in 40 CFR 262.27(a) lam ala u tity generator) or (b) (if turns small quantity generator) is true. <br />Generators/Offerors Printed/Typed Name jei 6). dexsignatu. <br />ciciCetiC),VP 7:,12 <br />Import Exp-ort. from U.S. Port of entrylexit: <br />Month Day Year <br />0 <br />—i 16 Intemaffonal S ipmel4t <br />Transporter signature (for exports only): <br />Ui <br />ce <br />a <br />Cl) <br />Transporter 1.Pinted/Typed Name <br />1C1I,1) r <br />Transporter 2 Printed/Typed Name <br />17 Transporter Acknowledgment of Receipt of Materials <br />Date leaving U.S.: <br />Signature Month Day year <br />I • 77 0./..?" di- r)(4 1°3 1 19 <br />Signatu Month Day Year <br />I I I <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity 111 Type LIII Residue II Partial Rejection [1 Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Month Day Year <br />2 <br />u_ Facility's Phone: <br />u9 18c. Signature of Alternate Facility (or Generator) <br />1— <br />LLI ta 1 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />3 <br />Month Day Year 20. Designated Facility Owner or Operator: Certifica on of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br />PrintedfTyped Name <br />Signature <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)