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Please print or type. Form Approval.OMB No.2050-0039 <br /> UNIFORMHAZARDOUS JJK <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking umber;^` <br /> $ 4 <br /> WASTE <br /> I 16X7 I-V4x 01991`24 MANIFEST �, ''h �.�.-. �s '. �'I ..) � `",�.�j <br /> 5,Generators Name and Mailing Address Generator's Site Address(if drfferent than mailing address) <br /> L,- <br /> Generators Phone: <br /> S.Transporter 1 Company Name U.S.EPA ID Number <br /> �lt�1Qa �I$Vt l�(�+11I:°I�T.�L' aEPt'4tit".E�5 INC. U.S. <br /> j <br /> �. x <br /> 7.Transporter 2 Company Name U.S.EPA iD Number <br /> 8,Designated Facifily Name and Site Address RAMO9 EtsMFtt*0,L%1TAL SEft Cis tple U.S.EPA ID Number <br /> 1611£SOUTH RIVER RD. <br /> Sf1fr$71$�T47 <br /> Facility's Phone: <br /> ga 9b.U.S.DDT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit Q.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.lvol. <br /> 1, NiXt RCRA fiAifRftDous$tYWM LIQUID�t.ED 014 221 <br /> o <br /> Z 2. <br /> ua <br /> t7 <br /> 3. <br /> 4. <br /> 14.S ectal Handling Instructions and Additional information <br /> 5 { l��tqq [5�t�;y�:pP��{yyDgyy l#. �p��{ ER,yCA 7.1Y q y��ry�y� i / <br /> RAND-r_RS O BE FLk'i44.��.tint!U /1P�"{iLJ1+�'D PPE }r " 'M' r'� �. �`� f• P'' F <br /> E.A. CowRACTOR. 6 AMOS EN\MO iMEWAL GEY{'`AMS <br /> t5. GENERATOR'SIGFFEROR'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 iabel"placarded,and are in all respects in proper condition for transport according to applicable intemationaland 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 cerltfy that th <br /> q waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI am a smajAvengy generator)is hue. <br /> Generator rot's Printedrr Nam ! Signature r Month Day Year <br /> � � <br /> 16.Intem banal Shipmere <br /> r Import to U.S. ❑Export from of lex t: <br /> ? Tranepofer signature(for exports only): D saving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials ;a <br /> Transporter 1 PrintedTryped Name Signature Month Day Year <br /> Z .Transporter2 PrintedfTyped Npn Signature-r A `' Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy tndication Space ❑ Quantity ❑Fype ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> �Z 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: Month Da Year <br /> I8ci Signature ofAltemate Facility(or Generator) - y <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codesfor hazardous waste treatment,disposal,and recycling systems) <br /> G 1, 2. 3. 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 /> Printedfiyped Name, Signature Month Day Year <br /> EPA Form 8700.22(Rev.12-17wrevious editions are obsolete. GENERATOR'S INITIAL COPY <br />