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e Form designed far use on elite 12 ilcil t ewrilli Form Approved.OMB No.2050.0039 <br /> Please r�type,( g ( p ) yP ) , q,tdanlfest Tracking Number <br /> 1.Generator ID Number 2,Pa e 1 of 3,E g n y es o se PhD �. <br /> UNIFORM HAZARDOUS 31?— G B F <br /> WASTE MANIFEST b- Lt <br /> 5.Generator's Name and Malling Atldress Generator's Sile Address(if different 11(ng address) <br /> Generator's Phone: U.S.EPA ID iNumbet <br /> 6.Transporter 1 Company Name �y 3 Q <br /> U.S.EPA lb 7,Transporter 2 Company Name('IU.SEPA D <br /> B.Des[nated Facillty ame and Site Address <br /> ' �Qv'1ti1`C�t; •CG��rs10..`f'z`c,�. J�iL� ,. <br /> 5Qowac� s�" X92—L�7-1 �e)q,6 <br /> Facilits Phone: <br /> 9b,U.S.DOT Descdpgon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers t1,Total V.Unit 13.Nlaste Codes <br /> 9a. No. Type Quantity WLNor. <br /> HM and Packing Group(If any)) ff <br /> LX qV <br /> �ON <br /> 3 00 <br /> L71v e' <br /> 06 1 <br /> 4. <br /> 14.SpecialHand�inglnstucgCos andAddillonallI mallon � �`Lr'S25—bVVI <br /> Yr <br /> 15. GENERATOR' FFEROR'S CERTIFICATION; I hereby declare that the contents of gds consignmenhara fully and accurately described above by <br /> the proper shipping name,and are cls Oiled,packaged, <br /> maned and SIOSlOdlplacarded,end are in all respects In proper condition for transport according to applicable thlemalional and national governmental regulations.If is shipmenl� am the Primary <br /> Exporter,I certify that the contents of this,consignment conform to the terms of the attached EPAAcknawledgment of Consent. �,,...• <br /> l cerilfy that a vi minimization statement identified In 40 CFR 26?.2(a)(If I am0.urge quantity generator)or(b)(Ill am a small quantity g oralo s True. Month Day Year <br /> Signature <br /> Genemlor's10fle s e ype ame, 1 ,t�� 1_ <br /> 24 <br /> ...� 16.laternaiion hipmenis port to U.S. P of it /axih <br /> ❑Export from U,S. ry <br /> p-- D ole v g U.S.: <br /> K- Transporters alure(for exports onty): <br /> w 17.TranspoderAcknowledgmentofRecerptofMatedais Month Day Year <br /> Slgnatu <br /> Tran Hari Plinio pod Name <br /> t G ... h:anlh Ray Year <br /> Ir Signal e <br /> Qranspoder2 rinledffypedNae <br /> 18.DiscrepancyType El Residae ❑Partial ReJeclton ❑Full ReJect!on <br /> 19e,Discrepancy indication Space El quantity <br /> ❑ <br /> Manifest Referenra Number: U,S.EPA ID Number <br /> w t8b,Alternate Factlity(or Generator) <br /> Month Day Year <br /> w Facility's Phone: '">'��"'�• <br /> 18c.Signature of Alternate Factlity(ei Generator) <br /> Q <br /> Z 4. <br /> N 18,Hazardous Waste Report Management hlethod Codes(todes for hazardeus waste treatment;disp3sal,and recycling systems) <br /> 2. <br /> LU 1' <br /> Year <br /> 20.Designated Factlity Owner or Operator;CedlReation of receipt of hazardous matedals covered by the morlifnss`except as noted in Item 18e <br /> Month DaY <br /> Printed/Type Name <br /> t= CN�TCD FACILITY <br /> DEsTfNATION STATS(li��>~QUIF�E®) <br /> EPA Form 8700-22(Rev.3-05) PreVIDUS editions are obsolete. E)._SI <br /> i <br />