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Please print or type.(Form designed for use on elite(12-pitch)typewriter") Farm Approved.OMB No.2050.0039
<br /> 1.G ne for ID Number 2.Page 1 of 3.Emergency Res ansa Phone 4.Manifest Tracking Number
<br /> UNIFORM HAZARDOUS re "� U ��'' ,.P
<br /> WASTE MANIFEST i. f C I` (, �..► "a . {,''�s"2645 �+J
<br /> 5.General rs Name and Mailing Address ='.k,,.is' .'.3,'>'•^sa ": ' ar Generators'SiteAddress(ifdiifereat than mailing address}
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<br /> Generatots Phone: 7=` t s # }
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<br /> �terk,jo�n r y l�arrt U:S.EPA ID Number.'
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<br /> 7.T,arisporter 2 Company Name { { r { a t1 .^ U.S,EPA ID,N-gmbej!
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<br /> B.O�sigrfatd{tF gi#lFy sad iia dress r. t{••v .� �.;_ ,. U.S.EPA IDNumber';
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<br /> Facility's.Phone:
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<br /> 74� dw3�i27Y' stnc-ons and AdJdi2anal y�i`n�forma°ion
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<br /> List r'i t '{
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<br /> 15: GENERATOR'SIOFFEROR'S CERTIFICATION:_I hereby declare that the contents of,thl�conslgnmentaro:fully and accuratelydesbabed above by the proper shipping naraeL and are classified,padfiaged,
<br /> marked and laiaetedrplacarded and are in all respedts in proper condition for trensporf accardmg[o applicable mtemabo"-'blind and_n�bonal g6�& ental regulabons[if e or ship>henF and f am the Primary
<br /> Exporter,I aerlify{liatthecantents:cf this'consignment conform td the terms of1F{e atiac�{er}`EPAAckndwieddmenf of Consent
<br /> certify that ilia waste minimization statement identified in q0 CFR 262.27(a}(if I am a large quantity generator)or(b}`(iff&6imall.gbanHfy generator)is tr e.' '• -<”' 1;.;
<br /> GeneratoeslOfferoes Printe ed l�am#fyef Signature l�E Month Day Year
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<br /> 1fi.lntematiortal,Shipments l '-s, -❑Impart to U S ' r ar❑Expait fydm US : r{ :'`Port of entrylezii
<br /> s Transporter signature{fOr ezportsiinly}i; "'';r ' ! {'_` "` r r r' Date leaving
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<br /> Transporter 1 Pririte0fTyp�e�r7{3N e t o. E Signature - Month Day Year
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<br /> Transporter 2 Prj tedfryped Name "" Signature A rQ V /'I Month, Day Year
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<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejaction 13F,11 Rejection
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<br /> Manifest Reference Number.
<br /> 18b.Alternate Facility(or Generator} U.S.EPA ID Number
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<br /> Facility's Phone:
<br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year
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<br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,andreeycfingsystems)
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<br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 118a
<br /> Printedrryped Name Signatur Month -Day Year
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<br /> EPA Form 8700-22(Rev.3-05) Pr{evious editions are obsolete. ` � ' DESIGNATED FACILITY'S COPY
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