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Pleape print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ('&('(0202 1171 1 00,2182436 JJK <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> /AJ I tl I,"i 1"101:°. 1 )19 A- <br /> k otb's tva,+t,Ift4e fit� 1`4 <br /> V, <br /> lot W;.Vlh <br /> Generator's Phone: s . <br /> 6.Transporter 1 Wp7 Name U.S-:,VPA ID Number <br /> pp �,i, <br /> - , ,! J <br /> -V <br /> 7.Transportbr-2,Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> [-,ltemWal <br /> Kr,'fleft"in 4 A V 4 9,71 <br /> Facility's Phone: <br /> 9a. 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 wt./Vol. <br /> 1 <br /> 0 <br /> Nf) 9,1 RVA0,27 11GI, III, lot! I yl, fX0 1 3 y <br /> MM with h"cW , '-�Nt plosi) <br /> L <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> P ;4 t('A,'4XiYR0 <br /> A,Yitf <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 /> marked and labelediplacarded,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 oedffy 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 true. <br /> Gener toes/Offlerors Printedrryped Name Signature Month Day Year <br /> 4,16-7 <br /> Trat,oe,, i" r,) <br /> -J 1 16.International Shipments <br /> P- El import to U.S. ❑Export from U.S. v n Port of ant At: <br /> Transporter signature(for exports only): Date lea4 U.S.;,/' <br /> L= 17.Transporter Acknowledgment of Receipt of Materials <br /> Li <br /> TranspoAr I Printedfryped Name <br /> Signature Mont4- Day Year <br /> 0 <br /> us t <br /> �zZ <br /> Z Transporleff 2 'n ed Signature kMonth Day Year <br /> I18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity 1-1 Type El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> LU T8—cSignature of Alternate Facility(or Generator) Month Day Year <br /> !7c <br /> Z <br /> 0 <br /> V5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0LU <br /> 1. 1 2. 3 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedrryped Name Signature Month Day Year <br /> EP-1A—Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />