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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No. 2050-0039 <br /> [FUNIFORM HAZARDOUS 1.Generator ID Number t i .- C 2.,P{age 1 of 3.Emergency Response Phone .Manifest Tracking Number <br /> 008 �,ASTE MANIFEST �n �� O �� FLE <br /> enerator's Name and Mailing Address y enerators Site Address(It ddFarent than mailing address) /\ S � <br /> • C;�J � r�.S` �''� t 1J c.�.�->c�.� �3 �:.�5,� �:GN�� � :✓ �; t lJ ` <br /> 0115 <br /> Generator's Pha1e 1 1. � '' 1 T7 '� S14 <br /> 8 Transp-ater 1 corn ny Jame U.S EPA ID Number <br /> �1� �� �`� ��� ► `C�� �nec��c.�.-�. ,���� iC,��.S� � ;��;1 <br /> Transporter 2 Company Name U.S. EPA ID Number <br /> 8 Des gnaied Faciii y Name and Site Address �,� } `, F; 1 l 4 b L` L US EPA ID Number <br /> CLED 1-10 6- bo c .�- b <br /> tau J--+0t.'w 111 1\ 0 _9 R:3. <br /> "acility's Phone: 7 GJ 6� <br /> 98. 9b U S DOT Description(including Proper Shipping Name,Hazard Class, 16%umber, 10 Containers 11 Total 12 Unit 13 Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity Wl.Nol <br /> '51.1 Li Cu 1 tj . U - S �<S C'r� C: y C A o rn I Lv i1'J <br /> ,� y �` r - <br /> t 01 P` 7D, <br /> 4 - - I—- <br /> 14,Special Handling Instructions and Additional Informatior - <br /> , <br /> 11 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that 14 contents of the consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAeknoWedgment of Consent <br /> I certify that the waste minimization statement identified in ad:CFR 262.27(a)(ff I am a large quantity generator)or(b)(it t am a small quantity generator)is true <br /> General s1Olfarw''l9 PrintedfTypeo Name Signature ,n on 3 ay ear <br /> IN\\^� I� � ��'. �Vl. 'ti� I �l1t�l /�jrS .�t✓ t.! ���'�,f'l5'�'•� ��� 9 ,�f� r <br /> -� 16 Intematrcnal Ship ants f�1 <br /> Import to U S !_1 Export from U S Port of on !exit _ <br /> Trans over sl nattne far exports only), - leaving-ETUPS 1 <br /> 17.Transporter AcknoWedgment of Receipt of Materials <br /> Transporter + PrinlFrIfTyped Name $ignalu e ��f Month ay Year <br /> Transporter 2 Prin edfTyped Name .19natum Month Day Year <br /> f'- I <br /> 18.Discrepancy 1 �� <br /> 18a Discrepancy Indication Space L j quantity O T pe <br /> y �Residue ❑Partial Rejection ❑Full Rejection <br /> _ Manifest Reference Number: <br /> 18b Alternate Fararty(or Generator) US EPA ID Number <br /> _J <br /> V <br /> Q <br /> LL' Faglli •5 PrionB' <br /> 18c Sgnalura of AN math Facility(nr Geneiatn) Month Day Year <br /> Q <br /> z <br /> 19 Hazardous Waste Report Management Method Codes fi e.codes for hazardous waste treatment,disposal,and recycling systems) <br /> iH1 41 7- <br /> . 3 4 <br /> 20 Designated Facility Owner or operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed dame Stgnature Month Day Year <br /> EPA Form 5700 22 (Rev 3-05) Previous editions are obsolete. DF,S)IGN&Gig FACIL"'170 DESTINATION STATE (IF REQUIRED) <br />