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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br /> 1 "I UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3 Emergency Response Phone 4 Manifest Tracking Number <br /> yIy WASTE MANIFEST , , F I C <br /> t 5 Generators Name and Mailing Address Generators Ste Address ( f different than mailing address) f LG <br /> I� 1� <br /> Generators Phone11 An I <br /> t tl E T ansperter 1 Company Name <br /> U.S. EPA ID Number <br /> 7 'riansporter 2 Company Name <br /> I " _ U.S. EPA ID Number <br /> 1 1%8 Designated FacityName and Site Address U.S. EPAID Number <br /> An 11 A A <br /> 11 11 A <br /> i Faclily a Phone' <br /> t, <br /> Pan 9b US, DOT Descnpton (including Proper Shipping Name Hazard Class ID Number, 10. Containers 11 . Total 12. Unit <br /> �r <br /> ' I and Packing Group ( f any)) fNo Type Quantity WCNoI. 13. Waste Codes <br /> � 1 <br /> © I <br /> � l <br /> 2. <br /> I f <br /> a I <br /> I 3. <br /> 3l i <br /> ilE g <br /> 1 <br /> 14 Special Handling Instructions and Addltlonel lnformat on <br /> . ,... _ <br /> ! C 'IS GEoERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents ofths consignment afully and accurately described above by the proper shipping name, and are classified packaged, <br /> narked and labeled/placarded, and are in all respects In proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br /> t t Exporter Icomythat the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> p I cetfy, that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (If I am a small quantity generator) is true. <br /> I Generators Offeror's Printed/Typed Name Month ay Year <br /> ' 11C t .ional Shipments <br /> � ❑ Import to U.S. ❑ Export from U.S. Port ofentry/exit <br /> ' a sp rtersi nature for exportsonl ): Date leavn U.S.: <br /> I = 17. Transporter Acknowiedgmentof Receipt off Materials <br /> © � Tr sporter ' Prnted/Typed Name gnature <br /> A Mont ay Year <br /> A AAz Tsp <br /> ranorter2 PnntedITyped Name <br /> Signature Month Day Year <br /> 18. Discrepancy <br /> Va. Discrepancy Indication Space ❑ quantity ❑ Type <br /> a f El Residue ❑ Partial Rejection ❑ Full Rejection <br /> y. � Manifest Reference Number: <br /> ¢_ 1 o`b. A!fernate Facility (or Gene2tor) U.S. EPA ID Number <br /> ¢ . <br /> FablftYs Pnone: <br /> © { 18c. Signature Of Alternate Facility (or Generator) <br /> . < <br /> I ase 10 :Jazardeus :Haste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> Noc +. 1 ' 2. 3. <br /> I pp 4. <br /> G20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In item 18a <br /> PrintediTyped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />