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Please print or type.(Form designed for use on (12 jAch)typewriter) Form Approved.OMB No.2050-OM <br /> UNIFORM HAZARDOUS 1.Generator ID } 2 Pape 1 of 3.Emergency Response Rade 4 Yarrtlest Tracking f4urlbar <br /> WASTE MANIFEST !�sr {�. %{ '"( -' 1 j{ "•- `t 1 000257463 I V I V V i <br /> 5.Generators Name and MalTng Address Generators Site Address(d different than mailing address) <br /> ` <br /> Generators Phone.; 1 I <br /> L- <br /> 6.T=, U.S. mber <br /> �. <br /> 7.TranWorlef 2 Company Name U.S.EPA ID Nrmrber <br /> 8.Designated Facility Name and SYe Address U.S.EPA ID Number <br /> Faditys Phone' <br /> gar 9b.U.S.DOT Desuiption(Mduding Proper Shfppirg Name,Hazard Gass,ID Number, 10.Containers 11.Trial 12.Uri 13.Waste Codes <br /> HM and Packing Group(dant)) No. Type Quantity WL/V01. <br /> 1. <br /> Z 2. <br /> W <br /> C9 <br /> 3. <br /> I <br /> 4. <br /> 14.Special Handing ImI uctiars and Adftm Information <br /> 15. GENERATIT WOFFEROR'S C TION:I Weby declare mat trre omtlen of this consignment are fuiy and acaaaWy described above try me proper st*Wq name,and ate classw packaged, <br /> marked and lebeledlplamsded,and are in 0 respects n proper condtion for transport according to applicable it Wallanal and national governmental reg rations.N export shipment and 1 am the Primary <br /> Exporter,l MW fhat the=49M Of this corddrm to the term of me aWied EPAAdvatdadgmenl of Consent <br /> I ow*Rmt the wasle m reruatim identified in 40 CFR 26227(a)(d I am a large quardy gararabr)or(b)(d I an a small quantdy generator)is true. <br /> Gerwators101ferors PMted/Typed Name Signature Month Day Year <br /> -j 16.Intemational Shiprrrads to U.S. _ <br /> ❑ ❑Fort Gore U.S. Pari ofsorry/exit <br /> Transporter signature(for exports only): Dale leaving U.S.: - — <br /> 4' 17.Trareporta Admo*Wgment of Receipt of h aterials <br /> (^y <br /> Signature Y <br /> ear <br /> 1Y A' <br /> zQ Transports Pn*KVTyped Name Day Year <br /> 18.Disaepency <br /> 18a.Discrepancy adIcation Space ❑ ❑Type ❑Residue ❑Partial Rq dkxr ❑Full Re)erbon <br /> Maru7est Reference Nurtber. <br /> 1 ab.Atlsmate Fatdrty(or Generator) U.S.EPA FD Number <br /> U <br /> Q <br /> LL Facility's Pfane: s <br /> W 18c.Signature of AJtemate Fac4ly(or Generatgr) w Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Codas(i.e.,codes for trazardow vntate keatrnenl,Qspoeai,and recymng systems) <br /> C 1. ( 12, 3. 4. <br /> ) <br /> 20.Designated FadGty Oww or Operator:Celtifir38on of receipt of hazardous materials oove�d by me mwalest ewapt as noted to Item 18a <br /> Pnntellffyped Name SViatre Month Day Year <br /> EPA Form 8700-22(Rev.3-05) PreMous aditipns are obsolete. TRANSPORTERS COPY <br />