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I IN <br /> IN NN- <br /> Please print or type (Form designed for use on elite (12-pitch) typewriter) Form Approved. OMB No. 2050-0039 <br /> UhIFORNZARDCIIS 1 . Generator ID Number 2. Page 1 of 3 Eme gency Response Phone 4 Manifest Tracking Number <br /> +'{ <br /> w . <br /> ,IN <br /> WASTE MANIFEST , f M � � � <br /> `•ry 'r3 '! sir # e nF ' <br /> � ' S G -reraorsNand Mailing <br /> aacl gAddess Generator's Site Address (if different than mailing address) <br /> i L1 # <br /> r s s sr , ¢ , ' t rf rAa.. .s <br /> Goner aIor's Pho , lk;c �.�aN„-,taa� i• " <br /> ansp -ter 1 Company Name <br /> t U.S. EPA ID Number <br /> I NII ;; .% a, . N d'.ftrW f1t"pil <br /> Iransporter 2 Company Name U.S. EPA ID Number <br /> 8. 'Designated Facility Name and Site Address U.S. EPA ID Number <br /> ift <br /> orf, <br /> .en1v <br /> , ,a. ,�.T'i%s 'q n NAP o,h <br /> F cl Paone: rm4 ;y <br /> ( u Mb. U.S. DOT Description including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> and Packing Group ( f any)) 13. Waste Codes <br /> No Type Quantity WLNol. <br /> l � � tui p 3Tbl'uDb ?1 'aw ) a. cin t , A vt.ra. _ ,n�}u <br /> l © ' +. i"' x R"vy3 . rff Er` 1 a = t£ ,g.. # snr;fi•••: M ? v3 a .a^ ' in --4. `[r ^a .x last"' <br /> " <br /> Z <br /> I <br /> )4. . - - _ <br /> ( lf So acial Handling Instructions and Additional InformationL <br /> I m Cf <br /> i } ill, R , <br /> I ' `nrNINON4l <br /> 15. GENERATOR'S/OFFERORS CERTIFiCAT ION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> snintiried and obeled/pl carded 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 /> lr rter I cant fy that theme f the eons gnment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I cartiry that he waste minimization sta.ement identified in40 CFR 262,27(a) (if l am a large quantity generator) or (b) (if 1.am a small quantity generator) istrue <br /> I . t. C.er.ra[ors/Openers PrntetllTypedNeme tgnawre month Lay Year <br /> I Pala <br /> —J 16international.Shlpmems ri <br /> o— t_I lmport to U.S. ❑ Export from,U'S. Port of entrylexit <br /> ransportersignature (for exports only): ate leavn U.S,: <br /> jof 17 T i t A k figment fR Receipt PI tenals <br /> Tr napo[ 1 in ei Name i ggn( [urILni §v ry ;y y Month ' a e r <br /> mN, r, gsa 3 )r vys R t ` d"'{+, F g;"," PVW9 F v „ tT„i. Vs` ,..,. . t1 <br /> .. � <br /> [ ZTranster 2 Printed/Typed Name S nature <br /> i <<{ .L Mont Day Year <br /> 'be <br /> � . <br /> ,3\ ).18. D'-cra?ancy .--. . <br /> ' ' a - screpancy Indication Space ❑ Quantity ❑Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Ifs <br /> Manifest Reference Number <br /> 18b. Akeenate Facility (or Generator) U.S..EPA iD Number <br /> F <br /> t3 _ <br /> I( n Facility's Phone; <br /> ` 18c agnature of Alternate Facility (or Generator) <br /> Month Day Year <br /> Z <br /> G 19 Hazardous Waste Report Management Method Codes ( .e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 4. <br /> 270. D 'onatea Facility Owner or Greater Cert cat on of reacepti hazardous materials covered by the manifest except,as notedun Item 18a <br /> {{ Prntoo7( ped Name ,y Signature �X MOMm -Day e'reaf <br /> I, I,f. ,; ..— <br /> 2 <br /> rN <br /> EPA Form 8700-2211itev 3-05) Previous editions are obsolete. L <br /> DESIGNATED FACILITY TO GENERATOR <br />