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.i + f,/ <br /> t yi'A i .- <br /> 4. <br /> Piease pri ORM HAZARD designed for use on,ehte(12-pitch)typewriter) <br /> OUS L Generator ID Number 2.Pag 1'of 3'Erri a" sep�p .M nifast Track)ng Number <br /> WASTE MANIFEST t`:pit ..ii;# 1,;; I � 7 l tit a ac <br /> 5 Generators Name and Mailin00 <br /> g Address <br /> Generators. eAddress(rfdifferaptthan mailing:address) <br /> rd, <br /> �nf �sf <br /> +14e� <br /> Generator's Phone: <br /> 6.Tfans�o)te1 t Company <br /> ,,s! ti +, U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address r <br /> i Ott r s.�ty }; ( L:4f.ii ;'GiS'�€�{yy ;x #,:� U,S.EPA ID Number <br /> Facilitys Phone: w rt t <br /> 9a. 9b,U.S,DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10..Contalners <br /> HM and Packing Group(if any)) 11.Total. 12.Unit 13.Waste Codes <br /> 1 No. Type Quantity WtNol <br /> � k1"� ,'` c .yy:i t t z.lr[:t. r t�;�i-�S •�.k !. -zp(��..f ,-�, . . `.- <br /> O <br /> W 2' <br /> s <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> C;, <br /> 15. GENERATORS/OFFEROR'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 labeled/placarded,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 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 Iarge,puanUty generator or if I am a small quantity Generaloes/Offeroes Prigte0 yped Name { ) O( Q ty generator)is true <br /> a: Signature <br /> r + _. !F')S ygS 9 f 1 C° fr7 fi q;;.•a rf Month Day Year <br /> ( f -�t. f t..� f�' 1 1 '' w'f.,"'".•""!,'4'°ro �'ff')./ �+ <br /> -J 16.Interns tionalShipments <br /> ❑Import to U.S. ❑Export.from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> D17.TransporterAcknowledgment of Receipt of Materials <br /> Tfansporterl Printed/Typed Name S g)ature <br /> Month Day Year <br /> Q <br /> Trans <br /> poit r2 PnntedITyped,Name <br /> Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue I ❑Partial Rejection <br /> ! ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number, <br /> 5 U.S.EPA ID Number <br /> Facilitys Phone: <br /> 186.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> r :1• 2: 3: 4, . <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered.by the manifest except as noted in Item-18a <br /> Printed/Typed Name Signature <br /> { p,: Month Day Year <br /> 4 Forin P700-22(Rev 3 05Previous editions are obsolete. DESIGNATED FACILITY T®GENERATOR <br /> Chu ;r -� <br />