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rn <br /> N <br /> L <br /> "E5 <br /> O 00 <br /> ry- <br /> nit <br /> _ Badding <br /> (d <br /> ...ental Heattn OePastynent <br /> O <br /> U - <br /> rr <br /> 'r f/�� 56Zjgg•OA <br /> i '04"Lge <br /> Form mead.OMB No.20500039 GuaO,lonr1 <br /> "ate <br /> Please tint or rype.IForm designed lar roc�n dllr n.phrnl tyV�,wnr1rl v,,q•trd re..urr.ror.yR��M1V4.���'}� JJK q <br /> 1 � _ <br /> rd1U l7 fik1l' r+degD�w <br /> UNIFORM HAZARDOUS 1 G" <br /> WASTE MANIFEST ,.....n.r ,ne n,ldns:m,rme,,,rl n.nn nra,rn9 aaaroee) pepp <br /> 5 Generaldfs Name and MU�lii"Ann, <br /> U.9.EPA ID Number �n <br /> EPAID Numbar <br /> I <br /> N•un- <br /> i I�EPH ID Nnmher d <br /> n�n;iynared Fay play N u q and Sae Adnms. 7 <br /> 1, t <br /> r � <br /> sa�dmrs Pnnna. 10.Containers r F,ral 12,Una 13.Waste Cede <br /> d Proper Shipping Name.Hazard Class,ID Number. an;aY WI No, <br /> 9a. 9b.U.S.OUT De—Prun(ru a mg No. Type ','A <br /> HM and Parking Group til anrr) <br /> K1' <br /> 0 <br /> o <br /> �e• <br /> 14.Special Handling Insauclions and Addrional I"Mm"on 1 <br /> dedare mal the mntems of Nis consignment are Nlly end accurately descdbe0 above by Ne proper shipp^9 name.me areclassified.pac0.a9ed. <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION:I herebym r condition for transport auoNing to applicable international and 19 overnmental regulations.It expoR shipment and I am the Primary \ <br /> marked and IaheledlplawNed and are in all respells in D Pa ment of Consent. k� <br /> Exporter. ceNly that the contents of Nis rons5nment wrdorm m Ne terms of Ne atbdred EPAAckn'east 9 Month DaY Veer \1\ <br /> certify Nat the waste minimization sblement idenCfied in 40 CFR 262 27(a)til l am a large quantity gs 9 aWfe°r(b)lAl am a small quantity generator)Is true <br /> GeneraroesrOMero(s Prinledrryped Name <br /> Pod of emayferrit'. <br /> � 76.Inlemational Shipments <br /> Import to U.S. El Export from U.S. Date leaving LLS,: <br /> z Transporter signature(for exports only): Monty Day <br /> ear <br /> w 17.Transporter tcknowledgmentoi R. iptol Materials Signature r <br /> Transporter 1 PrinledrFyped Name Monty DaY Year <br /> O Signature <br /> a <br /> z Transporter 2 PrintedRyDed Name <br /> Q <br /> K <br /> F— Full Rejectioni6.Discrepancy rResidue ❑PaNal Rejection <br /> r Type <br /> 16a.Discrepancy Indication Space �Ouantiry <br /> Y Manifest Reference Number U.S.EPA ID Number <br /> CY) � 16b.Altemale Facility(or Generator) <br /> O .� Month Day Year <br /> U <br /> r LL Facililys Phone. <br /> LO O w t6c.Signature o(Altemale Facility for Generator) <br /> O rl- r <br /> N Cfl z <br /> Ln ID19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Ireatmenl.disD35al,and recyd'mg sys ems <br /> 0 /_ e ro <br /> o 1_ 2. <br /> Q Month Day Year <br /> C I20.Designated Facilely Owner or Operator:Certification of receipt of hazardous materials covered by the m5 gnaturecepl as noted in Item 18a <br /> PrintedrTyped Name <br /> O GENERATOR'S INITIAL COPY <br /> N <br /> U cn EPA Form 8700-221Rev.3.05)Previous editions are obsolete. <br /> a) O _N <br /> UU <br /> L) cz <br /> 2 <br /> Z) > Lu <br /> 66 <br /> E U N O 0 <br /> NO <br /> U <br /> N = <br /> � � rn <br />