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Please p'r>' type (Form d signed for use on elite(12 pitch)typewriter) 9 �y p 9 <br /> 1 Generafo ID Number V � <br /> NIFORM HAZARDOUS 2.Page t of 3.Emergency Response Phone 4 Manttest Trackin Number �( <br /> WASTE EST i. t.. .47�).,'.<'r' e r�;� . ?: -514 <br /> i 41 .—rtr�r+t : yt,.t(t �„ ' , ) KS <br /> G <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> frd (l rt?f '4. t. }'it �• tI 7'f <br /> r., r,tlE k ts. ti`if L'� :M1ta [ . lIt.-E(t=' l,lt <br /> ..., '' a� ,tit`} _)r .'r•T t,td �l r rp`°,.; <br /> Generators Phone: 7" <br /> 6 Transporter 1 Company Name 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 /> .. <br /> .?r¢'it";f"t. <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including proper Shipping Name,Hazard ClassID Number, 10.Containers <br /> , 19.Total 12 <br /> HM and Packing Group(if any)) No. Type Quantity 12.Wt./Vol.Unit Unit 13.Waste Codes <br /> i <br /> .Z 2. <br /> ,W <br /> V <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> St' 300 .:�t>P, <br /> f b.; U.. H. r. t . tri: k •,. �i - �t..A,� a; 1140 <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and aocuratelydescribed 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 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.dentified in 40 CFR 262.27(a)(if I am a large quantity'generator)or(b)(if I gm a small quantity generator)Is true. <br /> eneratorsl0iferors Name Signature �a j ft Month Day Year, <br /> 16 Interna'nal Shipments <br /> Z ❑Import to U.S. FlExport from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> t2[Tl,�nspoqer 1 Printed/Typed Nae" gnatureMonth Day Year <br /> ansporter 2 Pri ediTyp Rama- <br /> Signature' Month Day Year <br /> 18.Discrepancy .� <br /> 18a.Discrepancy Indication Space Quantity ❑T ❑Residua <br /> yPe ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: i <br /> 18b.Altemste Facility(or Generator) ► U.S,EPA ID Number <br /> U 'iAr <br /> ua. Facility's Phone: <br /> W 18c.Signature of Alternate facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p <br /> 1• 2, 3. <br /> T <br /> 3 ! IA <br /> 20.Designated Facility Owner or Operator:Certification ofreoeipt of hazardous materials covered by the manifest except as hot Iterp.t a <br /> Signature <br /> r {� Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Prevl6us editions are obs e. f <Rts DESIGNATED FACILITY TO GENERATOR <br />