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rn <br /> co C0 <br /> M N <br /> O <br /> O <br /> ry- r a co <br /> n U <br /> O <br /> U r Form Approved OMB No.2050-0039 <br /> rr Please pnnt or I pe IF rm cosi nod for use on Old 12-pilch) BWfilar. <br /> I Gonombr ID Numhnr 2 PageEmergency Response Phu"', .Manliest 4NuMI <br /> UNIFORM HAZARDOUS r, 1 ` <br /> WASTE MANIFEST Gnneralays Sllo Addnis:.IiI�Gn��nnl Inert mailing addms <br /> S ianar:dnl's Nmiw Ind 410,11119 AA1 <br /> U.S.EPA ID U.S EPA ID N <br /> �Lir":.In.�ht,. .lulily NJnI!and"Ir ailtn�s.. <br /> Taal''s Phone: <br /> Sb,U S.DOT ID Number. 10.Containers 11 Total 12 Unit 13.Waste Codes <br /> HAI and PeckiN G ,d 1,101 No Type Quantity WI Not <br /> K <br /> O <br /> N <br /> Q <br /> uu <br /> w <br /> ou <br /> W <br /> O <br /> 14 Special Handling lnelmclions and Additional lnfonnalmn <br /> 16. GENERATOR'SIOFFEROR'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 la bolediplacarded.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 /> Expose[I certify that the contents of this consignment conform to the leans of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimiralion statement idenfified In 40 CFR 262.27(a)(if I am a large quant generator)or(b)(If t am a small quantity generator)is true. <br /> Ganeratols'OBarbes Printedrfyped Name Signature Month Day Year <br /> 16.Intemasersi Shipments <br /> ❑Import to U.S. ❑Export from U.S. Pont of enlrylexit: <br /> = Tansponer signature(for exports only): Dale leaving U.S.: <br /> w 17 TransponsrAcknowledgment of Receipt of Matenals <br /> ac Transposer 1 PnnledrTyped Name Signature <br /> p- Month Day Year <br /> es <br /> G Transposer2 PnntetlRyDad Name <br /> Signature <br /> r— Month Day Year <br /> 18.01screpancy <br /> 18a Discrepancy indication Space <br /> ❑Quantity 11 Tvpe ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> t6b.Alternate Facility(or Generator] Manifest Reference Number <br /> Y c4 U.S.EPAIDNumber <br /> a FacillVe Phone. <br /> LO <br /> W 16[Slgnalure olAllemate Fadlity(or Generator} <br /> M Z <br /> LO OQ y 19.Hazamous Waste Repos Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and roc clin systems) <br /> Menlh Day Year <br /> O O 0k20 <br /> C 2. 3, <br /> Y 9 <br /> � O Designated Facility Ownel or O p y 4 <br /> kdlT Operator Cenifcation of recei l of hazardous materials covered b the manifest except as nged in Item 18a <br /> Q L YDed Name <br /> Slgnalure <br /> C <br /> EPA Farm 8700-22(Rev,3-05)Previous editions are <br /> O � obsolete. Month Day Year <br /> GENERATOR' <br /> S INITIAL COPY <br /> U '�• _ <br /> Z) >, u LU <br /> rn c� <br /> X00 0 <br /> N O U <br /> N = <br /> � � rn <br />