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rn <br /> Co C0 <br /> L0 N <br /> C O <br /> O <br /> ry- <br /> n — U <br /> U <br /> 0 Please print or po.(Porto tlaslrr red for use on ellta ry2pnrhl lypewnlarl _ <br /> UNIFORM HAZARDOUS I.rn,u•nlnr In Nn,nn", i.Pope 10 3,Emn Form owed OMB No.105p-0039 rr <br /> WASTE MANIFEST rpenry 0.eopma Phorro 4. t nekkq N <br /> y 6 r <br /> I,raumr-,Namo end Mao��,I,�eti •-•Ir't'.p ':181 r LIMir f - JJK <br /> '..HN ti Genemlora Slle aklrea 1pddle,em Iron melllnq,edtmel t � <br /> .:T);l- ;VJF`.II HN flyer •' rrr... � <br /> ,'Ir 1N <br /> 1II11F1 •r.1 .Phone. <br /> ' I WD I.0 .•r ICmmpeny N,nn,. <br /> 7 Pali ,,,l„i,r!hf I U.S,E ID Nunn.•, <br /> 119. PAID N�mb�r <br /> a.Davgnatndrn ilnyNa,n+ai:l.tib Adrlo•.I. A <br /> l V.S.EPA ID Nunrbar <br /> I .. ...tIM, <br /> e4..Iry NV . <br /> 1 '1 � Fedlll Ph rte j' <br /> 1111 9a. nl V6 DDT Dnrr erne,l4'mMn SII^n N.vme.41 ra Gr•;.,ID Nun.•,, <br /> 1,'.Co rte rte,, <br /> NM 1F' Nu. Tyra ouantily WI Nu ... <br /> II t <br /> K <br /> 4p fN. tam <br /> w tic roe Od <br /> sn.l uy/k� <br /> of <br /> U v <br /> OGene, IJ Speaal Manmmg lnseunionsandAdtldional lnbrmatlon ,,eL li.p <br /> Waste <br /> co e�A <br /> Waste <br /> Notifir ozaym <br /> (n I5. GENERATOR'S/DFFEROR'S CERTIFICATION:thereby dedare mal me conlanls of this consigo replan fully and accuhnelydavmbeoabove by Ne propershhpmgname.ard meclassiL the <br /> packaged. 9ZlRa <br /> Shipm marked and Obeledlplararded,and are in all respao,m proper condilion for transportaccording to applicable international and national govemmental regulations.It export shipment arta I am Ne Primary ued� <br /> Exporter.1 certify that the conterils of this consignment conform to Me terms of[he attached EPAAcknowledgment ofConsent <br /> 1 certify Inas the waste minimization stalemenl identified in 40 CFR 262.27(a)(if am a large quantily generator)or(b)(Il I am....ll quantity generator,is we. <br /> UHC's Generators/ORemrs Pnnledfryped Name Signature MR�joctonO <br /> y Year ronrinne16 Intemational ShipmentsToes a = ❑Import to U.S. ❑Export from USParifen\rylexit. <br /> Date leaving U.SQ ryes, rY 17 iransponerAcknowledgmentotReceiptotMatenals() wC.1pn5tj aTransporter 7 Pnnled/ryped Name SignatureDay Year �ul <br /> es,0 z Transporter 2 Pmmedryped Name SignatureDay Year18.Discrepancy <br /> 18a.Discrepancy Indcation Space puantil y ❑Type ❑Residue Fu'�l Relep,ort) Manifest Reference Number: <br /> N18b.Alternate Facility(or Generator)_EFacilitys Phone <br /> w 18c.Signature ol'Allernate Facility(or Generator) h Day Year <br /> Q <br /> � Z <br /> O 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. <br /> to 1-0 a <br /> O O <br /> N <br /> L0 O 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> O p <br /> Q PdnfedlTyped Name Signature Month Day Year <br /> U <br /> 0 EPA Form 8700-22(Rev.3-05)Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> O E <br /> � � C <br /> Ur.•N��..,�u r,r tiV _ <br /> a) 0 without impermissible dilution of the prohibited wastes.I am aware that there are significant penalties for submitting ayfalse certification, <br /> C) the possibility of a fine and imprisonment. <br /> L) OCZ Waste Decharacterized But Requires Treatment For UHC(40 CFR 268.7(b)(4)(iv)) _ <br /> W <br /> _ ify under penalty of law that the waste has been treated in accordance with the requirements of 40 CFR 268.40 or 268.49 to remove the hazardous <br /> X00 0 <br /> N O CZ <br /> U <br /> N = <br /> � � ri <br />