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Form Approved.OMB No,2050-0039 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> �CM6anffqst Tracking Numbs► JJ K <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response PhoneTra � �WASTE MANIFEST °,+ f�,j,4 <br /> 5,Generator's Name and Mailing Address Generatofs Site Address(d different than mailing address) <br /> V{►N Lt r�'ir ( r.�T! +~�►.r�•t �Jw Va*1►.t Dt Pr.J. C MsZ �-j <br /> '1�'i:. 5 is►,- ��w ► w �r ��+�v F <br /> f•Tt'Cr-i _..t '.'+ t'�^ jF ��L�-ttR1 0f4 ''I`,s:.tC` <br /> Generators Phone <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facillirty Name and Site Address <br /> U.S.EPA ID Number <br /> Ve m5 F tLLD Tr r1ftI—F1 F- I•fit <br /> 1L a; [ . L-'K.c{nrLfA6I r rJ <br /> ?-,yt ,it-FII to it A r"' <br /> Facilitys Phone' t F ' <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Nunber, 10.Containers 11.Total 12 LkA 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity W Nd. <br /> K <br /> t.+Jhf�) (+;.C.tcif? 1�H'::�F'�i�tG�t):. Wr,a.Z•�;,I�C�t){G� (r,+i�� � <br /> z 2. <br /> LL) <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information-,.',, (:,T ( / C 11.Y �� (,t a 1.7 I <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,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 EPA Acknowledgment 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)(if I am a small quantity,generator)is true. <br /> Generators/Offerors Pi nted/Typed Name Signature ,r _ Month Day Year <br /> t ` -4 1,.J <br /> rj 16.Intemational Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexil: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Sg_Oture MpI{{t pay Year <br /> ZZ Transporter 2 Printed/Typed Name Signa urei Month Day Year <br /> F- <br /> F- <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ra+ Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. 2. T <br /> 4, <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a <br /> PrintedfTyped Name Signature Month Cly <br /> PAForm 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />