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.Y2 � w n t i`i'v� �f'a�f���a �,. ; ��'`b1Y'x.�- "^.�ifi.� ��a�1ya �• R�ry,.-. :.\ <br /> Please print or type.(Forth designed for use 01 elite(12-pitch)typewriter-) Form Approved.OMB No:20500039 <br /> UNIFORM HAZARDOUS, 1.Ge rarator D Number 2 Page 1 of 3.Emargency Response Phase 4.Manliest iraekvtp Number <br /> WASTE MANIFEST _ - L _ u ~� 7 ,r ( M W 1 <br /> 5,GepemWs Name and Malting Address Genera(Ors Site Address(d different than mailing;address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA V Number <br /> r <br /> jf'f.` r�r ,. f:. ?tel'JI <br /> ,.• -_ <br /> 7.Transporter 2 Company Name i U.S.EPA ID Number <br /> S.Dea{psaled Fac*Name and Site U-S.EPA ID Number <br /> Facis Phone' — <br /> ga. 9b.US.DOT Descdpdon(including P opLr Shipp6g Name,Hazard Class.ID Number. 10.Containers 11.Total 12.U.-* 13.Waste Lodes <br /> HM and Paoldrg Group(lt any)) No. Type Quantity WUVoL <br /> O <br /> z 2- <br /> tu <br /> C9 <br /> 3. <br /> 4. <br /> 14.SpedalHandfingIn3tructions ax1Addoona kdonraton <br /> 15. GENERALTOR'SfOFFETtOR'S CERTIFIC TIDlk I hereby declare tat the contents of this conaspnenf are fully and any described above by the proper shipping name,and am dasa6ed,packaged, <br /> marked and labeWpfacarded,ad ore in respects in proper condebon kx transport occ riling to aippkm*mternational and rational governmental regueabons.0 export shipment and 1 am the Pmnay <br /> Exporter,I novtify Gat Gra mrrturts of In certfortn to the Oertra of IheaCadred EPAAdmowdedgrrrent dConsent <br /> I certify Graf the waste rtd kizati 1 identified it 40 CFR 262.71(a)(d I am a large quantity generator)or(b)(d I am a small quantity generator)is true. <br /> GeneratorslDlferoes Print dfTyped Name Signature Month Day Year <br /> H 16.Intema8o al ShiparieMs ❑knx <br /> .,.to U-S. ❑Export from U.S. Pat of erby dt <br /> Z Transporter signal re(fir exports only): Dale 8 U.S.: <br /> Cf 17.TranWter Ad=wiedWnen1 of Pao*of M alerials .- <br /> Transporter 1 PmrleNTyped Name Skprahre _ AIaM Day Year <br /> Q Transporter 2nvh dfTyped Name Sigrradae - Month Year <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space ❑ fity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Raference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> tai Fadfdys Phone: <br /> W 18c.Signature of A tenate Faddy(or Month Day Year <br /> Q <br /> Z <br /> N19-Hazardous Waste Report Maagemrerd Codes(Ce.,codes for hazardous waste treatment,disposal,and recyc ig systems) <br /> LU 1. 2. <br /> 20.Designated Facirdy Owner or Operator of recti"of hazardous materials cove!ed try fie manifest except as noted in ttem 18a <br /> NrdwVTyped Now \ Signature �,.y MorAh Day Year <br /> EPA Forth 8700-22(Rev.3-05) I'Vious edifiat s are obsolete. TRANSPORTER'S COPY <br /> - +.:vt_�.a�x....:....:...... ."�' -.rE::a:,'.bc-_�. sir'M .-;1.+5#�cArt?:'7..-a -'•-ai�:� <br />