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j Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Ge tar N be/r Peg 1 of 3. a ency Re ponse Pho a 4.Manifest Troumber <br /> WASTE MANIFEST -L/®(/''7�V J /L eg �3® . 012117801 JJ K <br /> 5.Generator's Name an�7rygn Generators Site Address(if different than mailing address) <br /> Generators Phonr04C&;— C"" 7"� -1 -;W^ <br /> 6.Transpo 1Company Name U.S. AID Number <br /> , �f✓�/� yl/ JT/iYdl./JI.e//YZ <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> 8.Designate a" a itdm U.S.EPA ID Number <br /> 2 10 <br /> x',67 W141V c�iTy, � <br /> e. � 93��9 s�f86' F71 <br /> Facility's Phon <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) Ouardity WtNol. 13.Waste Codes <br /> No. Type <br /> W <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handli Instarctons and Addittio�fa I <br /> n <br /> f <br /> o <br /> rmation <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledliplacarded,and are in all respells in proper condition for transport according to applicable international and national governmental regulations.Ifexport shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quanfity generator)or(b)(if I am a small quantity generator)is We. <br /> Gt:agra lens Prints pep e v M a Signat / Month Day �a <br /> -j <br /> 16International Shipments Il I1 <br /> i Import to U.S. El Export from U.S. Port of sntrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans po d pe a ///I©�yy)-� //� Si urs <br /> W ,w 1,! !- '�.i/ i/ l.r Month �y Y <br /> pl <br /> rn <br /> Q TransportPrintetlfTyped N e Vy <br /> Sign Month Day Tear <br /> K <br /> H <br /> 18.Discrepancy. <br /> 18a.Discrepancy Indication Space ❑ Ouanti <br /> ty ❑Type ❑Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ra+. Facility's Phone: <br /> C3 18c.Signature ofAfternate Facility(or Generator) Month Day Year <br /> Q <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. 1M' 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certificaton of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> P'nt R�e`d Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous adkizollsarootisolete. DESIGNATED FACILITY TO GENERATOR <br />