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Please print or :ype. (Form designed for use on elite (12-pitch) typewr.ier.) Form Approved . Ob1B No . 2056-0639 <br /> at. UNIFORM HAZARDOUS 1 . Generator .D Number 2. Page 1 of 3. EmergenDy Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST S KS <br /> 3. Generator's Name and Maling Addoess Generators Site Address (f diferentthan maling address) <br /> Generator's Phone: <br /> 6. Transporter t Comparry Name U.S. EPAID Number <br /> 7. Transporter 2 Company Name U.S. EPA ID Vumber <br /> . . . . I >. <br /> 8. Designated Facility Name one Site Address U.S. EPA ID Number <br /> =adlily's Phone: <br /> 9b. U.S. DOr Ossaiption (including Proper Shipping Name, t•:ezard gess, l6 Number, to. containers 1 t, Total Q . Unit 13 . Waste Codes <br /> HM and 7abcingGroup ;'rfany)) Vo. Tape Cua•nhty WLA+of. { <br /> rx ._. ... <br /> its <br /> LU <br /> 2 w - <br /> 3. 1ly,.ti� lt � } <br /> 4. LNVI ONMEN "JA E 1 = TIS4A <br /> { <br /> ITINM <br /> -4. Special handing Inst•uclims and .Addibo•taf liflornatiom <br /> IF <br /> 15. GENERATOR'SiOFFEROR'S CERTIFICATION: I hereby de: are that the contents of this oonsignmentare fully and acaretelydescribed above by the proper shippng name arc are classtiled, packaged, <br /> marked acid labeledrplacarded, and are in of respects In proper condition for transport according to applicable international and naticral governmental regulations. If export strpment and I am line Primary <br /> Exportar, I certify tat the contents of this consignment conform to the term of to attached EPA Ackno ledgment of Consent.. <br /> I certify that the were minimization statement identified In 40 CFR 262.27(a) (if 1 am a large quantity generator) or (b) (dl ern a small quantity generator) is true. <br /> Generatcr'Offaror'sPrintedTypedNarm • . .. Sgnalure - Month Day Year <br /> It <br /> —+ 16. niernatlonal Shipments 171 Import to U .S. ❑ Export `rom U.S. Port of en:rylexit: <br /> Transporter signature (fop expWs only); Date ]saving U.S.: <br /> UM 17. Transporter AcknvMedgmerucfReceiOofMaterials <br /> OTransporter i PrintedlTypad Rama Signature Worth Day Year <br /> CL <br /> 03 <br /> Q ransportarQFrrltedA . . . Norma Sgnature Month D Yeaa, <br /> f Ir . %T ji " 7 {. <br /> 8. DiscrepancyOaOOOO <br /> ' Ba. Discrepancy Indication Space ❑ Quanti. <br /> y ❑ Type ❑ Residue ❑ Pariiat Re)ec6cn ❑ Ful ReJecBon <br /> Marifest Re erena Vumber. <br /> 18b. AitemateFaciity (or Generator) US , EPA IDNarrber <br /> U <br /> IL FadIVs Phone: <br /> W Ilk Signature ofAltemato Fadity (ot Generator) Alonlh Day Year <br /> ccz <br /> 19. Hazardol s Wasta Report Vanagement Method Codes ;i.e., codes for hazardous waste treatment, disposal, end recycling systems) <br /> G 1 . 2 . 3. 4. <br /> 20. Cesgnated Facility Owner or ,Operato : Celifiation of recelpt of hazardm materials caiere: by the marifest except as noted in kem 18a <br /> Frinted/fypedNameSiana:ura Month Day Yea <br /> EPA Form 8700022 (Rev. U51 Previous editions are obsolete. - ._ <br /> to <br /> tstlttt at; <br />€ <br /> 9 ' d £60Z6b660Z ;se} d00 : 0 ' 6toLZaeA <br />