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7-4,9 ©Z3c <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST Q t z zss-aR Z1 003038632 G B F <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different thanailing dress) <br /> !` d[s mower + SGt,J SrSIt <br /> N'ZuM g "Lv <br /> 8 SZ h- r �•� Sr, /rlc n�-ua,Gi_c!5334 j ��CW3 n, <br /> Generator's Phone: —p Ze v 2 p•t—�2.S D 1,0 d <br /> 6.Trans rter 1 Company Name �/ ) U.S.EPA ID Number <br /> �-NAM oil I I C too 7 1-L- <br /> 7.Transporter 2 Company Name f U.S.EPA ID Number <br /> 8.ck n- a W Iameta\nd Site Address y�,Ct�G.�s U.S.EPA ID Number <br /> &qV S <br /> ►9-two y <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Cortainers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No Type Quantity wt./Vol. <br /> 13.Waste Codes <br /> 1. <br /> trTOP T� 419 <br /> O <br /> w U► <br /> UK[9°I+ G.lcs �fa,n� �Ls t�v�•�t Dm bag 213 <br /> ✓ o-S, S. ?GZtt(Dcw) Cams, �;eS�l, Drn 300 0, <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and AdditionAJaformation <br /> p yr f r4�t Z$ �ce{ L�7 li I' `;°►S 3 o t I <br /> `t�n����OR2t+4-ao <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fulty and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,aruf are in all respects in proper condition for transport acxording to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent., r <br /> I certify that the waste minimization statement identified in 40 CFR 2fi2.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is True. <br /> enQra slOfferors�P,rinQtendlTy/p�ed Name knature, . Month Day Year <br /> 16.4ntoWonal Shipmentsr. <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry(exi:, <br /> TrarisporW:rsignature(for exports only): leaving U.S.: <br /> UJI <br /> 17.Transporter Acknowledgment of Receipt of Materials tr <br /> ��me <br /> O SoHato' Month Day <br /> 44 Year <br /> C I V <br /> Q <br /> Tifizier2 rinte yped ameMonth Day Year <br /> 2 <br /> 18.Discrepancy S <br /> 18a.Discrepancy l6cation Space ' <br /> ❑.Quaettty , ❑Type'' ❑ResiduePartial Rejection <br /> ❑ 1 ❑Full Rejection <br /> Manifest ReferenceNumber. <br /> 18b.Aftemate Facility(or Generatr <br /> Ar <br /> t Y , U.S'EPA ID Number <br /> � <br /> vo Facility's Phone: it<Ltd <br /> 18cSignatureofAltemate FaalitytorGne4 <br /> at � <br /> - _ <br /> Wonth Day Year <br /> idous Waste Report Managerriejit Ab ' s vraste treatment,disposal,and recycling systems) <br /> V . . <br /> Mrt 3. 4. <br /> i <br /> �' <br /> Hated Facility,Owner or Operatrx C itlbgBon,tif,tgcafpfof-h us materials covered by the man'de ex pj a's ncted in Item <br /> ype <br /> 1 5n th Day Y r <br /> EPA Form 8700 22(Rev.I evious editions are.obs©lete: <br /> DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />