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Se print or W&(Form des�ned for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Nu 2 Page 1 of 3.Emergency Response Phone 4.Manifest Trading Number <br /> WASTE MANIFEST ' j_t !,i_ 1 JJ K <br /> 1 01 <br /> 5.Generat Name and Mailing Address Generator's Site Address(d different than mailing address) <br /> A.c.MY�it <br /> Generator's PhonC.' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated FacfGty Name and Site Address U.S.EPA ID Number <br /> 4.EW!"t>)t''�S.'r7` It,f-rtyxv;h' _ <br /> :_t:�.j 1#t„?tii I}Y�-t'.:�t'E' `.', <br /> Fadlity'sPhone <br /> { A Tt,`'a Of cj S ,.1 K ^� <br /> 9a. 9b.U.S.DOT Description(ndud rg Proper Stipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Godes <br /> HM and Packing Group(d any)) Na Type Quantity Wwa• <br /> O 1 ::;.- .'-!-#?.?FA.I'�2'4:4l if-''uq TE. --R010 I+,'�i'ir`.i�..i•r�'i_+iM J <br /> ,1/,600 -- - - <br /> Z 2.LU <br /> f <br /> _ 1 i <br /> 4. <br /> f _�----------- <br /> 14. <br /> 14.Special Handling Inslnxtons and Additional Infom tion <br /> r 7 .w sal z >asr??1 A::s + . r;� ?•Estl�}� 7s . +,'t:t. f x# 9,B! . a 71 `PPOF)! #'P!1 ;Ji;. 'A00'—Z'st:�`f1 , EPA <br /> _ #40VFt *.�t€'#'is..��ti4iE . ft'keYrt�At <br /> M)!E:f;t+Iet36:i= F.'it <br /> 15. GENERATOR'SIOFFEROR'S CERTIFlCATION: hereby declare that the contents of this consignment are fully and acarately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in ad resp�ds in proper condition for transport according to applicable intemationaf and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the adached EPA Aduhowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(dt am a small quantity generator)is true. <br /> GeneratorslOfferor%Prmtedrryped Name Signature Month Day Year <br /> -i 16.Intematiora!Shipments <br /> F— ❑import to U.5. ❑Export from U.S. Port of entrylexit: -----_--_— <br /> Z Transporter signature(for exports only): Date leaving U.S.. <br /> W 17.Transporter Aduvwtedgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> ccO <br /> QTransporter 2 Printed/Typed Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.gwrepancy Indication Spaoe Quantity Type Residue ❑Partial Reje" ❑Fdl Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facti ty's Phone: <br /> w 18c.Signature of Alternate Faality(or Generator) Month Day Year <br /> t— <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Cod (-�,codes for hazardous waste treatment,disposal,and recycGrg systems) <br /> Q 1 2. 3. 4. <br /> L <br /> 20.Desiynalcd Faaly Owner or Qperator.Gertification rocoipt of hazarcloue materteta covered by rhe maNFast except as nand th nem 18a <br /> Printed(Typed Name Skjnafttre } Month Day Yeef <br /> c <br /> EPA Form 8700-22(Rev.3-05) Previous editions are te. <br />