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nM S <br /> Plea e t r type.(Form designed for use on elite(12-pitch)typewriter,) _ ®fuBii�50 9 <br /> ORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3,Emergency Res onse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST Vii.t7t t'i.e , , j;�t : (�# ,,, s ;�,f3s -";h `} �[I\S <br /> t a 4. 7 �� <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> • !%$_4 p f.:: � F �. .:'}�-.`r. 1.�i4 .?.� £'Ste : ' ordi 'R fl <br /> f„:, r '3' #it 1 Y tri("t ;5� fctl?i' <br /> Genetis Phone: (t( ` _ <br /> 6 Transporter 1 Company Name- U.S,EPA ID Number <br /> 7.Transporter 2 Company Name Number U.S.EPA ID <br /> •.. - <br /> 8.Designated Facility Name and Site Address U.S:""EPA ID Number <br /> .f rr f I JS ROAD <br /> D -i <br /> Facility's Phone: <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contaloers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> PG 11 <br /> w 2' <br /> c� <br /> 3• <br /> 4. <br /> 14.Special Handling Instructions and Additional Information �yy <br /> .. 3;....t}k ..i-i .. r�^�trF,"«(�,�..`��f"1 <br /> ?'f <br /> -J� <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately descrioed above by the proper sh(pp(ng name;and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable Intemagchat,and n�onet governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent. .'P <br /> 1.certify that the waste minimization statement identified In 40 CFR 262.27(a)(d I am a large quantity generatpr)or(b).(if I a all qua ilty generator)is true. <br /> Generatoes/Offeroes Printedffyped Name to <br /> Month Day Year <br /> —r 16.International Shipments <br /> F— ❑Import"to U.S. ❑Export from U.S. 0o of entry/exit: <br /> z Transporter signature(for exports only): Date leaving.U.S,: <br /> 17 Transporter,Acknowledgmentof Receipt of Materials <br /> oTransporter-1 Printedffyped Name 1plgnatu ;, Month . Day' Year; <br /> Q TransporterzPnnted/fypedName <br /> xSignature,V Month Dag Year <br /> 18.Discrepancy ' -"t . <br /> 18a,Discrepancy indication Space. Quantity ❑Type p ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate facility(or Generator) U.S.EPA ID Number <br /> a Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal and recycling systems) <br /> 0 1' 2• 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except es noted In item 18a <br /> Printed/Typed Name Signature --^z Month Day Year <br /> EPA Form 8700-22(Rev.3-M) Previous'editionirke obsolete DESIGNATED FACILII Y PO GENERATOR <br /> . �y <br />