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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050 0039
<br /> UNIFORM HAZARDOUS1 . Generator ID Number 2: Page 1 of 3 Emergency Response Phone 4 MamfeatTractan Number IjM
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<br /> WASTE MANIFEST '" : `� { ? '3 c �` �� art ),
<br /> 5, Generators Name and Mailing Address i, g Gonerato s Site Address (if different than malting address)
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<br /> Generator's Phone: r 00
<br /> B: Transporter 1 Company Name U.S. EPA ID Number
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<br /> 4.J5 t 1E ;gCt,VAI 1 , 3 f5q L�a �
<br /> 7. Transporter 2 Company pa y NameMP
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<br /> EPA D Number
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<br /> 8: Designated Facility Name and Site Address -'
<br /> t . F1 ; f f ya A,"q r f ,!i U.S, EPA ID Number
<br /> Fact ily 9b U.S. OT Description (Including�
<br /> 9a. Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit
<br /> HM and Packing Group (if any)) No: Type Q . 10talanfitY 12, Unit 13, Waste,Codes.
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<br /> Its RG7UENC't=D WAS"I.-L WAS P.ECErV , IIANDLED A ID Si'OrtII .
<br /> C�POSAL, 7Rt?A'17.iLY1' OR IZI.JjS i CROS Y ,g, rjVUzTOR ! � SttBSR i7
<br /> ,nu i Y IN UP[' Al S T}1L' PlC ?rY LINT 1
<br /> 3' 11 T}IC ENVIROUNIE NFAL IRO "C.Ti6? 1GCNr 2 A! t TIRE)} 1;.
<br /> r'i'SOtfr,CZ_ CONSEFVA?ION 'gip ` � C�k.? "'�'TC }S ' `"t. SSONS r
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<br /> 14:Spedal Hantlling'Instruc8onsandAdditional infotina{tion
<br /> C .. kas PbSs'z l 1 3 �S £ 519
<br /> if € 4 �n � � N IT AL HEALTH j
<br /> Er MENT
<br /> 10: GENE and la SlOFF
<br /> edipl ROR'S C nd areCATION: i hereby declare that 016 contents of this consignment are fully and accurately described above by the proper shipping name; and are classified, packaged,
<br /> marked and labeledlptacarded, and are in ail respects in proper condition for transport according to applicable intemationalapd national govemmental regulations, It export shipment and I am the,Pr maty
<br /> Exporter, I cerI that the contents of this consignment aonfontf to the terms of the attached EPAAcknowledgment of Consenl.
<br /> I certify that the waste minimization statement identified in 40 CFR 262427(a) d i am a large quantity( ) { r9 q ty generator) or (b) (iti a all quantity genara#gt) is true:
<br /> _ . CeneratoestOfle.-rs Printed
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<br /> t j f tx" s . Sr9n _ . ... Month Day
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<br /> 1? F � Year
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<br /> 16.*Inte tional Shipments
<br /> } ❑ ImporttoU.S, ❑ ExportfromU.S: Porto enWexit
<br /> i Transportersignature (forex 3ttsonly): _.
<br /> I F Trans rter 1 nn ed/i ed Name p Si atur Date leaving U.S.:
<br /> i 17; IransporterAcknoMedgmentofRecei tofMaterials
<br /> r1' Po .l' ' yp
<br /> 4 9n e,.
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<br /> Month Day Year
<br /> Transporter PrinfedrType Name
<br /> �r Signatures
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<br /> h t ' `(' t 6 ' li r
<br /> � Month Day Year
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<br /> i8. Discrepancy [ ?" � � I
<br /> 18a. Discrepancy indication Space
<br /> ❑ Quantity LJ Type [:],Residue
<br /> Partial ftejecticn ❑ Full Rejection
<br /> F 18b. Alternate f aclity {o; Generator) Manifest Reference Number.
<br /> s � t1:�: EPA iD Numbed l
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<br /> Facility's Phone:
<br /> 18c; Signature afAitemate Facility (or Genamtor)
<br /> Month Day Year
<br /> 10. Hazardous Waste Report Management.Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
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<br /> 2
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<br /> 20. Designated Facility Owna or Operator. Certification of receipt of hazardous materials covered by the manifest except asnded in Item 189 .
<br /> Prtntetlflyped Name
<br /> ,,�" 3gnature
<br /> EPA Form 70 -22 Rev 3 05 Previou dr � �j r � { Mon,ih
<br /> Day, Year.:,.
<br /> ( ) itions are obsole�(e:
<br /> f' DESIGNATED FACILITY VO GENERATO
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