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Please Qnttgr,type, (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3 Emergency Response Phone14, M'a�niffest Tracking Number <br /> WASTE MANIFEST - 7 ri FLE <br /> 5. Generators Name and Mailing Address Generator's Site Address if different than mailing address) <br /> f_' <br /> Generator's Phone'. - - <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 7. Transporter Company Name U.S. EPA ID Number <br /> e Desgnaled Na nd. teAddre - <br /> �pLhQ' $s - : .. . - - . _ , ' U:S. EPA ID Number <br /> "Ga P® �rc %Kia- knit; Mlf3 11QD0 wc4fi �.5 1 Yh txa ; VJj <br /> �➢e�tty, A!V i <br /> Facility's Phone: ;'= <br /> ga, 96. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (fany)) <br /> No. Type Quantity Wt./Vel. <br /> didILD G {CHROI f[fJltd. f J I T. <br /> P 4 <br /> O 'J -___-_-- <br /> w <br /> z 2. <br /> O �' 3 <br /> 3, <br /> 4. <br /> 1 <br /> 14. Special Hantlling Instructions and Additional Informationftjod <br /> .>s <br /> GENERATOR'SIO —EROR'SCERTIFIGATIOfI_,h�r byd cla,�tha[.CIte_cpllte0tsafU6i5 AsigDmenta[elully�andaccundedly desc✓load abDve by the-p[opersttipping�ame.,aud.azeclassifed,-packaged, <br /> -- - -_ <br /> marked 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 l am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (ii I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br /> Genemtorm/Oiferor's Printed/Typed Name bignature Month Day Year <br /> *A' ' % <br /> J 16. International Shipments — <br /> r— <br /> El import to U.S. ❑ Export from U.S. Port of entrylexit: - ' <br /> z <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> Dd 17. Transponer Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> az <br /> Transport <br /> zz 4. "k <br /> er2uPrMtednybedNme Signature -'- " - "' `Month Day Year <br /> K <br /> r <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> F 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> r+- Facility's Phone: - <br /> w 18c. Signature ofAltemate Facility (or Generator) Month Day Year <br /> zz <br /> y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment,:disposal, and recycling systems) <br /> WO 1 . 2. - 3. 4. <br /> r< <br /> 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> P t dFyped Name - Signature / Month Day Yea <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />