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Please print or type.(Form designed for use 00 elite(12-pitch) Form <br /> Approved.OMB No,2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator IP Number 2.Page 1 of 3.Fmerger"Response Phone 4,Manifest Tracking Number q { <br /> WASTE MANIFEST ,,; i..J J C1t,i til — <br /> '4 �^ -a _ w000257463 3 M Y Y <br /> 5.Generators Name and Mailing Address Generators Site Address(d ddkxeM tari ma4Ylg address) <br /> Generators <br /> 6.Ti CryJOT U.S.lk4ju'- rnr--�� kz <br /> �. <br /> 7.TransPler 2 CaWay Name U.S.EPA ID N comer <br /> 8.Designated Facikty Name and Site Address U.S.EPA ID Number <br /> FaaWs Phone; - <br /> 9a 9b.U.S.DOT Description(nn cludirg PSttippi g Name,Hazard Cass,ID Number. 10.Containers 11.Tow 12.Unit <br /> HM and Pag Groff(if ant')) No. Type WLAkL 13.Waste Codes <br /> Pang <br /> Z 2. <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> 14.Speciad Handling Instructions and AdM=W Warmation <br /> r F <br /> r <br /> 15. GENERATOR'S/OFFERORS CERTRU :I hereby declare ttet the mderris of tds mrmgnment are k*and accurately described above by tie proper stepping name,and are classified,packaged, <br /> marked and labefedlplar�ded,and are in respects in proper condition for transport aowrding to apptaahie international and naborrdt WmwnerW regulations.K export shipment and I an the Primary <br /> Edo W,I cer*that the oonterds nt It coosoweant conform to the terms of the attached EPAAdn owledgment of Cwmt <br /> I cadify Qat the waste mi�San identtied in 40 CFR 26227(a)(ti am a large quantity generator)or(b)(d I am a sal quay*generator)is true. <br /> Generatorsl0lferors PrirwaNTyped Name Signature Month Day Year <br /> A.3 J <br /> 16.international ShiprnanlCs ❑Impart U.S. ❑Export h.U.S. Pat of entrylexlt — <br /> Transporter suture(for exports on)y): Date leaving U.S.: <br /> 17.Transporter AdmoMwVnerd of Rept of Winals <br /> aT 1 � � Signature� ear <br /> QTra Printed/Typed Name Day Year <br /> 18 Discrepanq <br /> 18s.Discrepancy IndicationSpace ❑0.nNy ❑Type ❑Residue ElPartial Rejedion ❑F m Rgedion <br /> Manifest Reference Nun ben <br /> 1 ab.AJternate FaciRy(or Generator) U.S.FPA ID Number <br /> U <br /> Faality s <br /> PIM.- <br /> LU 18c.Signature of Alternate Fadtity(a Gtr) k Month Day Year O <br /> Z <br /> N19.Hazardous Waste Report Management W400 Codes(i.e.,codes for hazardous waste treatment,dsposai,ad regdkg systems) <br /> 2. 3. 4. <br /> { <br /> 20.Designated Facility Owner or Gperator of receipt of hazadeus materials rAue fd by ere ma niest except as rromd m Item f 8a <br /> Lir t <br /> Prin�ilyped Name Skfnatrxe month Day ear <br /> - <br /> "1 t <br /> EPA Form 8700-22(Rev 305) Pratious editionsobsdete 7RANSPORTER'S COPY <br /> I` t'*✓ !'3p, S l�hf'.:.'^r'�.'. }m'w•3' a[...''{ " <br />