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Please print or type. Form destgned for use on elite(12 Itch)typewrites ,: FormApproved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracldng Number <br /> WASTE MANIFEST > • :_, 1, � ' f,. .. JJ K <br /> 5.Generator's Name and Mdllrtg Address Generator's Sile Address of different than mailing address) <br /> Generator's Phone a <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> , <br /> __.•'i:?i rr;.F'f ilii! 1.t3,j,5U'�:i. iris: <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> I <br /> 8.Designated Feciky Name and Sne Address U.S.EPA ID Number <br /> Fadi tys Phone: :;;i I: <br /> 9a• 9b•U.S.DOT Description Qnduding Proper Shipping Name,Hazard Class,ID Numb, 10.Cen�inera 11.Total 12.Unit <br /> HM P h9 Group R any)) No. Type Quantity yyinci. 13.Waste Codes <br /> fil`�E RECYCLA �RVICEV RIALTO fIAGILITY,EPA <br /> ANU WILL <br /> _. .._._ _ <br /> AS <br /> 4. < <br /> , <br /> 1 1 <br /> 14.Special Handling Instructions and Addition Information <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: 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 /> marked and IabelaXplacarded,and are In all respects In proper condition for transport according to applicable international and national govemmental regulations,If export shipment and I am the Primary <br /> Exporter,I certify tho.ihe c6h to of this consignment conform to the terms of the attached EPAAcknowledgment of Consent_ <br /> I certify that$ero6aste m fadon statement Identified in 40 CFR 262.27(a) I am a large uan enerator or f <br /> ()Cd r8 4 tl1y 9 ) ()(iNam a smell quantity generator)is true. <br /> Ganerator's/Ofleror's Pt6 Name , Signature i Month Dey Year <br /> L. ••. ..�� ^i r'' . <br /> F 16.Inte_rnationalShlpm@nls <br /> Import ❑Export floor U.S. Port otantryledt <br /> z Transporter signeturp(hof expords only): [tier's leaving U.S.: <br /> <W 17.TranspoderAdwOvledgment of Receipt of Materials <br /> i2 Trans¢ 1 Printedffyped Name i; Signature / ,( � Month Day Year <br /> z Transporter 2 Pdntg yped Name ' <br /> Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑T <br /> Ype El Residue ❑Partial Refasten El Full Refection <br /> Manifest Reference Number: <br /> 18b.Alternate Fadlity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL FacilitysPhone: <br /> w 18c.Signature ofAltemale Fadity(or Generator Month Day Year <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1• 2. 3. <br /> 4. <br /> 20.Designaiad Facility Owner or Operator.Cer incation of receipt of hazardous materials covered by the manifest sxcept as noted in It4 198 l� <br /> Printetitryped Name SI�14- <br /> 1 r (c! a bay, ear <br /> }� e'y .�t S �rf `Jr;�. .Y,1 ` ,_l.-. ..i�+j ...•{ �•rl, <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete• (GESiGsVHiEi1 FACILITY TO GENERATOR <br />