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w • � <br /> Please print or 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 Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST k '*° k <br /> 'L E"LF sR'.2• 9 �' 3+1 C ", w r <br /> 5.Generators Name and Mailing AdcV� Gene i (If erent than mailing address) <br /> F <br /> I,41a 4 ,fe11 <br /> del <br /> tI125 N Ti�it#VYBWIII <br /> ' 'fW ►t3flrtn��0 <br /> rtry,nd '-A 1.117W xti, Tw.y.CA q1N304 <br /> Generator's Phone: <br /> 6.1 ransporter 1 Company Name i U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> I f:_,r-(,tb.44t <br /> f.4100%.i t nolo:.swrot v4 6ititftx <br /> f4,,. 1�,WrHJW3 <br /> Facility's Phone: 840,239 194,v NVI ,� <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste CD <br /> No. Type Quantity Wt.Nol. nt <br /> 1. d <br /> o 104 1993,Vis1[§t: F l,iru2lt hta,1.itgttllat,�.( .5., {, yt ? {G t t'`�' °`:: r CJflt ?t1t�6 <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> k-WEPGFNCY CONTACT T .EFF RHODES <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described abova by the proper shipping name,and are classified,packaged, <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 I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true.. <br /> Generator eros Printed[Typed Name ( igna on ay, Year <br /> -J 116.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter si nature for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name r ignature fMonth Day, Year <br /> Q Transporter Printed/Typed Name Signature r= Doth Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) Y.S EPA1Q Number=2 <br /> Facility's Phone: 2E <br /> a� <br /> Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z JAN 2,5 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W 1. 2. 3. "ENVIRONMENTA •HEALTH <br /> JFDeignated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the man fest except as noted in It&,ltia'`='t`i{ Iv't t-Ryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />