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Please print or type,(Form designed for use on.elite(12-pi(c}tj typewriter} ! f <br /> UNIFORM HAZAkDOUS 1•Gener'tor•ID Number .z,PB a Form Approved.OMB No.2050-0039 <br /> ^ssM t��� �� �r g 1 of :3.Emergericy Response'Phone 4.Manifest Tracking Numbei <br /> WASTE MANIFEST ,x #' v <br /> , f� <br /> 5.Generator's Name'rand Mpiligg.Address <br /> f G"enefatb s` ite;"Address(irdifferenf than mailing address} <br /> TA 9411,15T. <br /> Generators Phone <br /> 6.Transporter 1 Comparijr <br /> y ; j U,S"EPA ID Number <br /> :?i '12�A Cr ��t. !•-(5:.1»`' tr ti'£>'�F`i k4,^,.r: r:t <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Pacility+Name and Site-Address• <br /> 11.5.tVA1t)Number <br /> a1_B�1`vl �7 L� �ftia;s r <br /> Facilit('s Phone <br /> ga• 96.U.S.DOT Description.(induding ProperShippirig Nama Hazard Class,ID Number, <br /> HM and Packing Group(if an t0 Contafhers 11.Total 12;Unit <br /> No. 'Type -" Quantity Wt.Nol. 13:Waste Codes <br /> Q ' : �. rY:f 4.1 1 :j'. . i d-fi•y't�11''•''��l t..�.l..fe�{L�F�K, i. t ,j.•... <br /> JX <br /> 3. <br /> 4. <br /> t__ ,1. ,'.f � 'l3.':. , r } i' r P;i('t�t f:G; •` <br /> Q' -.,r 9 t C r s{� l .'.k :.<. (,�• {tv.i` -t s 1< <br /> c <br /> t <br /> _. <br /> KS pecial Handling Instructions and-Additional Information <br /> TVA <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contentsof this consignment arefullyand accurately described abova by the proper shipping.name,aril are classified,packaged, <br /> marked and labeledfplacarcled,and are in all respects in proper.condilion for'transport according la applicable international and national`governmental regulalions.If export shipment and I.am the Primary <br /> Exporter,I celffy that the contents of lois consignment conform to.tlieterms of the attached•EPAAcknowiedgmentof Consant. . <br /> I certify that the waste minimization statement idenlilied.in 40 CFR 262.27(a)•(jf I am a large qupniriy generator)or(b){if I m a small quanti _generator)rs true. <br /> Generatbes101ferpr's PnntedNped Name SfgtiatUre f" -f <br /> 1t Month Day Year <br /> .r 16.international$hipmerits <br /> z .Import to U.S.. Exporttroln U.S: : Port af;eniry/exit, <br /> Transporter signature(for exports only): Date leaving egil, <br /> w .17.TransporterAcknowledgmentofReceipt ofMaterials <br /> ry- <br /> Transporter 1 PrinledrTypedName Signatute <' Month" .Day. Year <br /> Transporter 2 PnntedfTyped Name <br /> l; e Sinature. <br /> Moniti, Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space D Quantity ❑Partial Rejection ❑Full Rejection <br /> O Type Residue <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U:S.EPA ID Number <br /> —1 • <br /> U <br /> Facility's Phone: <br /> 0 18c.Signature of Alternate Facility lot Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(Le:,codes forhazardous waste treatment,disposal,and recycling systems) <br /> Lij <br /> 20.Desrgnaled Facrhly Owner or Operator:Certification of receipt of hazardous materials covered by the manifezt,ez�epPps noted In Item 18a <br /> i Da Y Year. <br /> Si natural : Ph ; <br /> Printedffyped Namat g <br /> t t, # t tF 1 ' <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> FA K.3'HTO GE-INE: - <br />