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rn <br /> C0 <br /> Co N <br /> i _ <br /> Lf) O <br /> O <br /> Ina� <br /> 0 Hent <br /> Please print or type.(Form designed far use on elite 12-1 fypewrller.) <br /> '� UNIFORM HAZARDOUS I c^'+;rneir In Number Form Approved.OMB No.2050.0038 <br /> 2.Page I ut 3 Emeryaney Respin•;n Fhune 4./'y IIHI Tra<Ylny NumMr <br /> O WASTE MANIFEST l}]- 7 6 6 JJ K <br /> 1 <br /> U !.n, n;•r-N,119.;nd Mnliny Address Genor:imr'r.SllaAddmr..iii li(le;enl than maillny oddment <br /> Iz ER <br /> canamtora Pnoi;e <br /> e Transpodm 1 7rnnuairy N—I, <br /> i/s eve lD rm�nner <br /> 7 T;amsponer`;wnPanv Niilu• <br /> V S EPA ID Number <br /> R Desiynan•il l.i.auv Nanir•rind Site Add,- <br /> US EPA ID Number <br /> FurlldlS Pnnn,- <br /> ga 9b <br /> V.S.DOT De•...imlrtm pneludmg Propar Snipping Nana,Hazard Class,ID Number, 10.Conlalnera <br /> HM antl PaCkinO Grnup nI,myl) 11.Total 12,Unit 13.Waste Cafes <br /> 1 I No. Type Ouanbly, WI r/d, IG <br /> !! I <br /> O <br /> NO <br /> I W <br /> Z _ <br /> W No. <br /> r � <br /> r <br /> 3 <br /> U <br /> (0 _ <br /> IJ.Special Handling instructions antl Additional Information <br /> O <br /> C _ <br /> 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, <br /> U) marked ser and label <br /> ed/placarded.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 /> ExpoI certify Thal the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent — <br /> I certify that the waste minim-tion statement identified In 40 CFR 21(if I am a large quantity generator)or(b)if I am a small quantity generator)is true. <br /> Generalor'..lferors........ <br /> ....../Typed Name Si nature <br /> L 9 Month {Day Year I. <br /> .� 1b.International Shipments <br /> 1 �f <br /> � i ❑Import to U.S. ❑Export from U.S. Pod of entry/exit: <br /> T iranspoder signature(for exports only): Date leaving U.S.: <br /> Ow 17.TranspoderAcknowledgment of Receipt of Materials <br /> U O Transporter 1 PrintedlTyped Name Signature '..lonih Day 'ear _ <br /> a <br /> O <br /> imnsponer2 PnntedlTypeO Name Signature 9 Monts Day Year <br /> N I- <br /> 1__ 18.Discrepancy <br /> 0 <br /> 'W 18a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Resitlue ❑Partial Relechon 00 Full Rejection <br /> C <br /> -DO Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> _ J US.EPA ID Number <br /> E U <br /> Y Facility's Phone: <br /> w 18c.Signature ofAllernals Facilily(or Generalorj Month Day Year <br /> � Q <br /> (� Z <br /> LO ti 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w1 <br /> p 2. 3. <br /> LO O <br /> O r <br /> N Ln 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> C3� <br /> Prmled/Typed Name O Signature Month Day Year <br /> 0 _U EPA Farm 8700-22(Rev.3-05)Previous editions are obsolete GENERATOR'S INITIAL COPY <br /> c <br /> O � <br /> C <br /> C p '1 FURTHER AGREE TO ACCEPT THE ADDITIONAL CHARGES FOR LEGAL <br /> �_ DISPOSAL IF THIS WASTE IS OVER 1000 P.P.M.TOTAL HALIDES,OR X <br /> U U C CONTAINS ANY PC.E'S, <br /> CY) W PRINTNAME W <br /> U rn 2 <br /> LLI <br /> N C/) N O 0 <br /> CZ <br /> NCy) <br /> N0 U <br /> N = <br /> � � rn I` <br />