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rn <br /> co C0 <br /> ILO N <br /> O <br /> O <br /> _ ILO <br /> n <br /> -2 ' <br /> O <br /> U <br /> a) Please Pont or typo.(Form designed for use on e111e 12 Itch)typewriter) Form Approved.GMB No.2050-0009 n�Oroved.OMB Nc <br /> I.Gummed.,ID Number 2 Pepe I of 1.Fmnrgnnry rte mm-Minnn 4.ManNeal Trukinp Number Impar <br /> UNIFORM HAZARDOUS ��•_ ,— <br /> WASTE MANIFEST K <br /> 'C:111II!la4n'n Numr.iI1J Miilll111 A'141nn•, x.r <br /> et.dnl-,SII ANlmsIII Aillnlanl Ihlm nalllml luldraec) 1 <br /> Il� r::I'hnno <br /> ili l`^pn ItLlllpany Nalnn U.S.EPA ID Numbv <br /> Ii.liy..,n+:1'�ngnnry Nelnn U3.EPA ID 14, m <br /> .n;nl,nuu.l 1,01v Na mb Ind Sea Add 11 US EPA ID Numbe, —� <br /> Ferilil)✓e Phone: <br /> no U.S.D01er,„nlin fin, <br /> A, P ,Shlppinp Wine,Hazard Claxx.In Nu,,,N1,, 10.ConWlnbrx 11 Total 12.Urn <br /> ,'l1 .end PanoN Grunnn'nnv n No Type Ouannly 111 Nc1 tq.Ylaxlb CtAea yt`�Ie! <br /> �j <br /> (e I <br /> I I _ <br /> I <br /> 0 <br /> Ol 14 SpeGal Handling ln5lNcppns and Atldiaonal Information <br /> N 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, ge`- <br /> -0 marked and labeled/placarded,and are in all respects in proper condition for Imnsport according to applicable International and national governmental regulations.If export shipment and I am the Primary y <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> 0 I certify that the waste minimization statement identified in 40 CFR 262.17(a)(it I am a large quantity generatorl or(b)(if I am a small quantity generator)is we. <br /> Generafors/ORerofs Printed/Typed Name Signature MDay <br /> 16.Inlema01111 Shipments <br /> Export from U.S. Port of entry/exit.Transporter Signature(for exports only)' Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of MaterialsK Transporter 1 Printed/ryped Name Signature O aZ Transporter 2 Printedriyped Name Signature <br /> N a <br /> C <br /> 18.Discrepancy <br /> r) 18a,Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> C <br /> � Manifest Reference Number: <br /> E 18b.Alternate Facility for Generator) U.S.EPAID Number <br /> J <br /> Y c� <br /> LL Facilitys Phone: <br /> 18c.Signature ofAllemate Facility(or Generator) Month Day Year <br /> N <br /> Lf) C'7 <br /> O O 019,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C\j 00 <br /> Ln Co 1. 2. 3. 4. <br /> Q O <br /> U � 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the marded except as noted in Item 18a <br /> Prinfed/ryped Name Signature Month Day Year <br /> O C <br /> C <br /> U <br /> in EPA Form 8700-22(Rev.3-05)Previous editions are obsolete. GENERATOR'S INITIAL COP <br /> a O <br /> U U CID <br /> ,,.II 11 ��l lxd v,if 1�. 1 ,,.,i,.�l = <br /> r _� I ;,Ia•yr 11rguCn i:,:tri-!•:.- 1 w1 11 m... -.L,I m: W <br /> C) O o <br /> (3) cy) N O U <br /> N = <br /> � � rn <br />