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rn <br /> co C") <br /> L0 N <br /> O <br /> O <br /> ry- tD <br /> it <br /> f. <br /> � 1 v <br /> O <br /> U Please print or ly a.(Form desi ned for use on ellle 12-Itch)1 writer. <br /> rr UNIFORM HAZARDOUS 1 1.Gel.1—lD Number z.Penn t of 4 Pmnnlnm.H..: r. Form Approved.OMB No.2050-0039 <br /> y I l 4.Mnndeal TncMlnp Number <br /> WASTE MANIFEST !t t i l I A _ n- N <br /> 6 Generalnl:v Nmm,and Moling Addmss rnnelalni r.sdn Adnr«r;otrbtbnaa n,mm�albn { <br /> .I 0 eddrnne) <br /> 067 <br /> Gnnnralnl�;Ph.un <br /> 11lensn 11 f'rmnsnn11.1 irnlnnnV N,Inu <br /> UN <br /> IJ u.EPA ID Nmnfar <br /> Lampwlnl 31:e1npmiy Nam,. <br /> IIn 6 <br /> .S.EPgINumber <br /> N U,!�idnnll i�niild{N,nn.,uiJ:lh•4l.11, <br /> I15.EPA ID Number <br /> I.i <br /> '11 t)ti J�IIf,.,,rir,ll.n nnnl10111 Pmpur Shipping Nam.,It—Clnss,ID Numhrr. 14 Conlemers Il.role) tl Unn <br /> {hl and k'.,Mn.1 r:l;nlII,n1y11 <br /> Na Type Quantity An Ir'l ti'Na,ic%r. <br /> I <br /> 0g5 b'M 1a13 <br /> �kSE xql <br /> .x'til U41 <br /> of 1 <br /> 1 <br /> . X11 <br /> U - <br /> � I <br /> O 14 Special Handling Instructions and Additional Information <br /> 0 15 GENERATOR'S/OFFEROR'S CERTIFICATION;I hereby declare that the contents of this consignment are fully and accurately described above by me proper shipping name,and are aassided.packaged. <br /> -0 marked and labeled/placarded.and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and t am the primary <br /> Exporter I certify that the contents of this consignment conform to the terms of the atlached EPAAcknowledgment of Consent. <br /> 0 1 cemry that the waste minimization statement idenssed in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a small quantity generelor)is no <br /> Generators/0fieror's Pdnted/Typed Name Signature Month Day Year — <br /> 16 Intemallonal Shipments <br /> T = ❑Impanlo U.S. ❑Sport from U.S. Pod of entrylexit: <br /> Q Transporter signature(for exports only): Date leaving U.S.: <br /> O W 17 TmnsporterAcknowledgmenlofReceiptof Malenals <br /> U Transporter 1 Prioled/Typed Name <br /> _ Signature Month Day Year <br /> O C, <br /> rn <br /> - Q Transporter 2 Pmdad/ryped Name Signature Month Day Year <br /> C <br /> L .E 18.Discrepancy <br /> C. I 18a.Discrepancy Indication Space II��J <br /> 0) LJOuanliry LType ❑Residue ❑Partial Rejection ❑Full Rejection '— <br /> C <br /> rn Manifest Reference Number: <br /> _DC (� f8b.Alternate Facility(or Generalor) US. EPA ID Numhe ^ <br /> C U <br /> Y LL Facility's Phone: <br /> 18C 7 Signature ofAllemate Facility t 9 ry(or Generator) Month Day Year <br /> f� I kLILHazardous Wasle Report Management Medhod Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> CD N � 72'0� <br /> 2 9 <br /> Lr) <br /> signated Facility Owner or Operator:Certification of receipt of hazaMous materials covered by the manifest except as noted in Item 18a <br /> Q rtled/TypedName <br /> a) Signature Month Day Year <br /> U <br /> c <br /> p PA Form 8700-22(Rev.3-05)Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> a C <br /> U <br /> a O in <br /> 2 � W <br /> c = rn6 <br /> C/) E) 0 <br /> CZ <br /> 170 <br /> a) 170NO U <br /> N = <br /> � � rn <br />