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Please print or Form Approved.OMB No.2050.0039 <br /> P type.(Form designed for use on elite 12-pitch) <br /> ( typewriter.) <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Enwgmcy Response Phone �Vrjlt Tracking Numbs494. <br /> �� <br /> WASTE MANIFEST _t' <br /> 5.Generator's Name and Mailing Address ( ebre Address(if V#4 N, t L 1\ 1;\1: ��'r b ti,;r _ .1(_ ( different than mailing address) t <br /> C)I4T , C rr �r�....^4Ic:,µT Cw%ILL I•C <br /> t:• •cit _ <br /> Generators Phone' rl 15`.-10 <br /> 6.Transporter 1 Company Name <br /> U.S.FSA ID Number <br /> 7.Transporter 2 Company Name ^ P•. <br /> U.B.EPA ID Number <br /> \ , - cam• <br /> r+. <br /> 8.Designated Facility Name and Site Address U.B.EPA ID fotber <br /> V�1 N 5T. <br /> ytltriA t1�• �G�-InS- <br /> Facility's Phone " <br /> AZ n p- `, <br /> 9a. 9b.U.S.DOT Description(including Proper Shippkg Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WtNol. <br /> � 1tJCfJ- k[.kf� Nr1Zt:lkdOJ` Y�ff1'�T? t SC�1-iL C!I..-`�7 <br /> 0 ILA E,R,1S f Ab,50 ,% tv f� <br /> W t "A <br /> z 2. <br /> hu <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information \ r O1LS-i DE 1K�5 'F It%� ��1 <br /> 11 '=51 <br /> k , tc., T,_ .i r c <br /> 15. GENERATOR'S/OFFEROR'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,padcaged• <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 Prknary <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 26227(a)(if I am a large quantity generator)or(b)('d I am a small quantity generator)is true. <br /> Generatoes/Offeroes Printed/Typed Name_ SignaheeMonth ay year <br /> 16.International Shipmentsz <br /> f— ❑Import to U.S.' ❑F_xport from U.S. Pot of w y►eldt <br /> Z Transporter signature(for exports only): Deb beNttg U.S.: <br /> w 17 Transporter AclmovAedgment of Receipt of Materials <br /> Transporter 1 Pdntedfryped Name tare - Month Day year <br /> O 1 <br /> Q Transporter 2 PrintedrTyped Namemon` ' Signature (h pay y <br /> ear <br /> 18.Discrepancy � <br /> FAftem-ate <br /> Discrepancy Indication Space Quantity T <br /> ype El Residue Partial Rejection ❑Full Rejection <br /> Man fest Reference Number. <br /> Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LLe: <br /> ff1c;SgnatureofAlternate FadNty(or Generator) Alonfh Day Year <br /> 19 Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20,Desgnated FacAily Owner or Operator:Certification of receipt of hazardous materials covered by ft manifest except as noted in Item 18a <br /> �prwTtadrryped Name Signature <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />