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Please prir&type:(Form designed for use on elite(12-pitch)typewriter:) Form Approved.OMB No.2050-0039
<br /> UNIFORM HA7►�)tQOUS 1•Generator ID Number 2,Fags 1 of 3.Emergency Response Phone d,Manif st Trac In Number
<br /> WA5T�MANIFRST /Z, 1 '"�5� � 8' 632
<br /> 5,Generator s Neme and Malang Address Generaloes Site Address(if different than ntall(ng dress)
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<br /> Z-<�Y`t52�--- v Mca.Y�•�.�i�$- + .�a'Y q'''tr S"`O 7.a c)
<br /> Genoratot's Phone: 0 U,$,PPA ID Number
<br /> 6.Trens orter i Company Name 11,71
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<br /> 7,Tronspotlar 2 Company Name U.S.EPA ID Number a 7�-a
<br /> 412t ti
<br /> B.Designated facility Name and Site Address r���¢.S, U.S.EPA ED Number
<br /> Facilll s Phone:
<br /> 9b,U,S,DOT Doscdpllan(Including Proper Shipping Name,Hazard class,ID Number, 10.Qontelners 11.Total 12.Unit 13,Waste Codes
<br /> HM
<br /> ea, and Packing Group(if any)) No:' Type Quantity Wt.Nol.
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<br /> 2�Z,c h c�� c,.3G.s��- ,�,M► Ltfe t-5„Oh pr►�i ' �� _ ''�
<br /> X05, �, �7� [Wnvt� C�o►s, ►���s�l'
<br /> 4.
<br /> 14,Special Handling Ina ructions andAddlllonUnformatfon ry. f L;��jw p1/VJ �Y�'F` t=�'^+�`M t S,On S.10 t r
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<br /> 110
<br /> 15. packaged,
<br /> 11 11 porrAurd ac U lthl
<br /> GENERATOR'S10FOC3RIIFIICAIi4 enshipment and I am the Prfmary
<br /> marked and labeled/placarded,and In 911 in proper for according ngo applicable
<br /> Exporter,I cedlly that the contents of this consignment conform to the terms of the attached EPAAcknowlsdgment of Consent.
<br /> I certify that the waste minimization statement Idenlliled In 40 CFR 262,27(a)Of I am a large quanttly,generator)or(b)Off am a small quanllly generator)is true. plonlh Day Year
<br /> ?gnbYe z 8
<br /> _Generat 4
<br /> t101tero{tsPtEnledd}Mped Name
<br /> :'�•° ' ! �Jtl�l Jr r,•�Y �} CJ/ ��u�?�L'�if��t.JSrs�� - .....; _ , ::h:'p.. '•r
<br /> r 16.•injeVpadanat Shipments ❑import to U'll t; ,Porto enl lexll:.
<br /> Export ircm U,S, ry
<br /> Joe', 'S::
<br /> Tranq;bOrf9r$Ignalure(for exparls only):
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<br /> 17.TmnsporlarAcknowledgmentofReceipt OfMaterials 9rg'nalur Month oay Year
<br /> Trans iter 1 rl a yped N mo
<br /> C7 Month Day Year
<br /> T ns ortar2 11113 ypad e am tr"• ' „•$Igoe e —
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<br /> 18.Discrepancya.' �•'--�� ❑Pertlal Refection ❑Full Rejection
<br /> r--1 01YP,8 1. I Residue
<br /> 1$a,Discrepancy lftdleallonSpace
<br /> I`'(; ;i `'t` •:; 3,. Manifest Reference Number: U,S,EPA ID Numher, `
<br /> 186,AIlerne(e FaciNty(or Genardtot)„' �;ti•`j° ff}':Yn:.:,} ` ...,7:`.•".r i.'a.,
<br /> .yr �Iy� .;C_•,�,yi
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<br /> U r.i�,?h t��;:a5ig ,' 'ir:)i;?J�r �t�{f:•';; %i ; R,i r".� Month Day Year
<br /> d i• '1`i'4:aa(arits'��r .L'�Y•41t'•`i'o�•i. e fr1,(r.,: ,
<br /> i Facility s Phone:
<br /> 1,8c,Signature of Alternate Fadlhy'(gr Gegal�lar)`• - ��'"'r rt4•;;;��3�.s-t::'
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<br /> taihad d (((s r o'�ta�drApus�vastQ treatment,disposal, recycling sjst4.
<br /> and re II ems
<br /> ez tdaus Waste Report Manage0/� fll( (` N ,
<br /> 1W V
<br /> e manifest except a3 nctedln Item 1813 Monti, Day Year
<br /> a'° `;.gip;.r"I rated Faclllly Owner or Operator.Codi¢calionni,ieelpFof•haiar$ous materials covered by fh Signature
<br /> i. Qas..
<br /> t r PJlplaoi typed Name`
<br /> GS T ii�A"i'iON ST'ATC SIS
<br /> EPA Farm 8700-22(12ev;iQ•0 ), `evlous ed(Ilons aregbst lets: i;-IN �ACiL TV 10 0"
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