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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.20500039 <br /> } UNIFORM HAZARDOUS 1.General.,ID Numbert �� t e s j 2Page tvof 3.EmelgenQyrR!?hnaa Phoney 4Mamfest Tracking Number <br /> WASTE MANIFEST "� ;"; G B F <br /> 5.Generator's Name and MailingAddress <br /> t y.7I . ap fa Y 4 i Generator's Site Address(fdifferentthan,real inga dress <br /> L.P �.L%[ LY, d .tL.i .aI.F�C"Y' ..� R S"���.. �t9:d4 �'. .t1,6.. ( 3�. �Vx J* � e fT <br /> Gemeratofs Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name US.EPA ID Number <br /> 8.Designated Facility Name and Site Address qq�y Sot p 'Y'r1.�y n t-ft i d U.S.EPA ID Number <br /> pS.,Jpp <br /> ,.9.#i31� <br /> Facility's Phone: <br /> go. 91h.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WI Nail' 13.Waste Codes <br /> 1' i f6i r 'F( 1 _�-{;� i � r,=Ei E 1/ I " r VDI <br /> ' •i.i., <br /> I j <br /> W <br /> Z 2 <br /> W <br /> (9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional <br /> AdditionalInformatioon <br /> XyAt flIEV \ ifl, :lir14l') ' 011 <br /> } - j ) jfy <br /> WAT IM <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,.and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmentaf regulations.If export shipment and I am the Primary <br /> Exporter,Icodify that the contents of this consignment conform to the tennis of the attached EPA Acknowledgment of Consent. - . f <br /> I caddy that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)is true. <br /> Generatoisl0fferors Prmtedlryped Name Signature r' - Month Day Year <br /> i <br /> 16.International Shipments <br /> f— ❑Import to U.S. ❑Export from U.S Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: j <br /> our 17.TransporterAcknowledgmenl of Receipt of Materials <br /> K Transporter1 Printed/iyped Name Signature ' Month Day Year <br /> afarr <br /> Z Transporter 2 PrintedlTyped Name Signature <br /> ! <br /> Q 9 - Month Day Year <br /> K <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type Ll Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> out 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 l 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name s Signature , r .�onth Day Year <br /> A <br /> EPA Form 8700-22(Rev.M5) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />