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V9 <br /> Please print or type. (Form designed for use on elite (12-pitch) typewriter.) - Form Approved. OMD No. 2050-0039 <br /> '. .UNIFORM HAZARDOUS 1 Generator ID Number, 2 Page t of 3. Emergency Response Phone 4 Manifest Tracking Number p <br /> WASTE MANIFEST G `� � t � ua: c 2 F� J ry "�'�� � OO �� L � � � �.. DAT <br /> 5. Generators Name and Ma ling Address A^ fl q: A;p;,;,,. , tk ( doftet• Generators Site Address (if different than mailing address) <br /> tCC ttlfit 1TCYu :�T,x2': Cx. .. t Ic� IUSU � T[Ys.� ITT, cert v>w') MA � <br /> 51 wcy C,�=� ,. 'Crr�ct, t•E.. f��a,�a <br /> k Si <br /> Generators Phone ?Gi`•:3`� `f�7go <br /> 6. Transporter 1 Company Name - U.S. EPA ID Number <br /> CAROXr.Qi7 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number. <br /> Ifi-[Ptd Cxck �T e, ! Ott : 7 CON=? 4% Tf <br /> 8. Designated Facility Name and Site Address - U S EPAID Numh r <br /> US Ecglapyft SwIry R r; ,1 tCk k-00 <br /> . � .*a�k� 4c tied , SUt �t"�Tdyr. <br /> Facibtys Phone: <br /> ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13, Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WI Nol. <br /> F , rt,.r (C TIG , 7 (tn� deF� � ff .d <br /> Ni <br /> Z 2 <br /> 3. <br /> 4. v <br /> F <br /> 14. Special Handling Instructions and Additional information —, 3.10 160 22.3` k - <br /> 0 07012AZX 265T <br /> 'CAf,ru" zF'r i� a . c _,_I..� v D;.:.t�ir�5 cc rr. cxi t.rw r �cc-_ta , n el ..v c e . 's.EEa Cr . a yy..� n,, ( �,:;� . <br /> 15. GENERATOR'SIOFFEROR'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 /> marked and labeledlplacarded, 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 /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. - <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is Was. <br /> GeneratorslOHerors PrimedifTyped Name Signature / r Month Day Year <br /> J 16.International Shipments <br /> ❑ Import to U.S. ❑ Export from U.S. Pod of entrylexit: <br /> z Transporter signature (for extends only): Dale leaving U.S.: <br /> w <br /> 17. Transporter Acknowledgment of Receipt of Materials <br /> Transporter PiinledRyped Name Signature - 'Month Day Year <br /> QTransporter 2Printedrryped Name t 1 / - �` - Si/gnre�,r � �'f Month . Day' Year <br /> Ac. ! ' lt (.' ! I �filjlf' lf� f _. ../ / /f_ t /;z le <br /> 18. Disc I repAcy <br /> 18a Discrepancy indication Space ❑ Quantity ❑ Type El Residue ❑ Pamal Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> JUL- Facilty T/'.. - <br /> w 18c. Signature of Alternate Facility or Generator) - - Month Day Year <br /> a <br /> z - <br /> w <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous wastetreatment, disposal, and recycling systems) <br /> ( <br /> - 20. Designated Facility Owner or Operator: Certification of receiptof hazardous materials covered by the manifest except as noted in ltgm'1Sa <br /> Printed/ typed Name (� (� Signalure ( ` Month Day gYear <br /> fifiliEPAForm 8700-22 (RO- 3-05) Previous editions areobsolele:..3 - '" - - DESIGI ATEDFACILITYTOGEgERATi <br />