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Please print or type.(Form desiOned br use on elite(12•pi(ch)ty 3wriler. Form Approved.OMB No.20500039 <br /> T I.Generator ID Numtrgr 4 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS ( C / (;L' r <br /> WASTE MANIFEST ( /)�: UOCJ C ..i f `!✓ ! ;j'/% i 1, _� : li i l)t �.�' + _T K <br /> neratce,Name and Miri'mg Address Generator's ReArldress(it different than m 1liq address) <br /> 6/ ' (,(,":'.I "I(IlA ¢ ��hd/Jr' I-S .� <br /> ;7joo w-e�! 1vrtSkirity 1 7r, <br /> Generator's Phone: !l`!� '' ( <1 J a l % ` f U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> )l'.1'�+I(_b� cj\ <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> B.Designated Facility Name end Site Address { i.. _ r U.S.EPA ID Number <br /> r > <br /> F s Phone: <br /> ga 9b.U.S.DOT Description(Incbding Proper Shipp'.ng Name,Hazard Class,ID Number, 0.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(1f any)) No. Type Quantity Wt Not. <br /> 0 <br /> �i 2. _ <br /> C7 <br /> 3. <br /> 4. <br /> Specla Handling lnstructionsandAdditional lnformation <br /> !t!rl r X'Dl�i�ft I Jl'i' ll.%fill c d/ <br /> 15. <br /> 15. GENERATOR'SIOFFEROR'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 end labeledlplacarded,and are In all respects in proper condition for transport according to applicable international and national governmental regulations.It export shipment and I am the Primary <br /> Exporter,I ced4Ilial the contents of this consignment conform to the terms of the attached EPAAckrwwf*n ent of Consent. <br /> I certify Ilial the waste minimization statement Identified in 40 CFR 262.27(x)(if 1 am a large quantity generator)or(b)(d I am a small quantity generator)Is we. <br /> Generator'sMeror's Pr(rdedlTyped Name oelune./� Month Day Year <br /> / I <br /> Ill.International 3hipments <br /> ❑Import to U.S. Export from U.S. Port of enirylaxih <br /> Transporter s.nature(for exports only): Date leaving U.S.: <br /> 17.TransporlerAckrweledgmeM of Recnlpt of Atsterials <br /> Transporter 1 Printed/Typed N@me Signature f Month Day Year <br /> y )f_`l, . I •� ` ` Signature <br /> A'onth Day Year <br /> Z Transporter 2 Printed/Typed Name 9 <br /> 18,Discrepancy <br /> 18a.Disorepancy Indication Space El Quantity ©Type F]Residue ❑Partial Rejection ❑Ful Resection <br /> 'I{•1� 1•{,� '�)�IItl1�l I''. i. j 1 r'� i�''/II I',:• i !' %i1r./ f f �L41��N�/� �J �"lf��ll"'•� i� !' i <br /> f'/+ %. '_.r�'i•l i i ll1!� '�; ' � ,; ' / " Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 0 <br /> tai. Fac;litlls Phone: <br /> W 18c.Signature of Alternate Fac;Lty(or Generator) Month Day Year <br /> Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> t2O.Designated Facitity O,sner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> n( _ 'pedNam� 5gnalure� / A1m1h Day Year <br /> r'r J (` l ! !til <br /> t i,l l:. (,' ' _Ilf (:(ey.. <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete, I)G SI QP A7( D I rAC I1..1'h Y-I'o G E N r Fl AT0 rt <br />