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Please print or type.(Form designed for use on�liie(12-plat)type-der.) ' FormMproved.OMB No.2050-M <br /> UNIFORM HAZARDOUS 1.Generator ID umbo 7 Page 1 of 3.Emergency Response Plane 4.YarxihdTracldnp Number A/�,J�/ <br /> WASTE MANIFEST 0101" �` �/'4 ' 1►Y' <br /> 5.GerarakXa Name crud Make Address Generators Sie fMftssr(d dwerard than maig address) <br /> Generators Pnme: t <br /> 6.Transporter 1 Company Nam U,S.EPAID Number <br /> S Oro 'f t <br /> 7.Transporter 2 Company Name U.SlffAIDNumber <br /> . <br /> B.Designated Faatly Name and Site Address U.S.EPA M Number <br /> F Rhone:! t �z ' c <br /> ya 9b.U.S.DOT Description(ir)duding Prophr Shipping Name,Hazard Class ID Number, 1o.Cahners. 11.Tote) 12.Urd <br /> HM and Packing Group(day)) No. Type Ouantly YVWDI. 13.Waste Codes <br /> cc1 <br /> z z <br /> us <br /> O <br /> 3. <br /> 4. <br /> 14.Special Handling kxstruc6Dos and AddkWW ld MOM <br /> 15. GEHERATOWSKWFERoxs :I hereby dedare Oka(the dents at this consignmentare hey and acugately described above by the proper shfppirg mare ad are classified,packaged, <br /> marked and IabaledVacerded,and are in all in proper condition for transport accadng m appirable idernahonalad nallienal governmenU regulaGor>s,if exput sMprhhed and I am the Primary <br /> FVorter,I her*that Ole ca ft is of bets t conform 1D ire tams of the attached EFA Admwledgrrent of Consent. <br /> I certify Nal the waste minimization stalerrerr(idem fked in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(dl am a small quantity generator)is kue. <br /> GereralofslOteror's Printed/Typed Name Slgret m Month Day Year <br /> r <br /> 16 IntertxationaT <br /> ❑tmgxort U.S. ❑Export from 11.S. Pohl of entry/andt -- <br /> Transporter signakue liar exports only): Date laavkg U.S.: <br /> W 17.Transporter AdmowledgrixadofRec*of <br /> I& TransporW 1Kane Sr nakae Montt Day Year <br /> O �{ •''� r <br /> CL i, ; <br /> Q Trrso <br /> apW 2 m <br /> yped Name" <br /> SignaYae Ydar <br /> 18.Discrepancy <br /> 18a.Dscreparay Indication Space ❑ Out ❑Type ❑Residue ❑Partial R"KSon ❑FA Rejection <br /> Manifest Reference Number. <br /> 18b.Ahemate FadRy(or Generator) U.S.EPA ID Number <br /> J j <br /> a <br /> LL Fadkty's Phone: <br /> W18c.Signature of A bKnate Facility(or Generator) "th Day Year <br /> Q <br /> Z <br /> y19.Haurdau Waste Report Management Method (ie.,codes for hazardous waste treatment,disposal,and recydng Systarths) <br /> O 1. _ 2. <br /> 20.Designated Fa*Owner Or Oommtur Certhrafion ofreceipt hazardas ulmals novo*by them ax¢ept as nded n beam 18a <br /> Prnted/Typed Name Sigr atxre Month Day v, Year <br /> EPA Form 8700.22(Rev.3.05) Prewious editions 06 OlMleie. TRANSPORTER'S COPY <br /> i <br />