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1 <br /> Please print or type.(Form designed for use on elite(12 pitch)typewriter.) ( Form Approved.OMB No.2050 0039 <br /> UNIFORM99 <br /> 8 11.GeneratorIUNUMDer 1 (Al S}r3'J l �E�f` 2.Page 1 of a Emergetncy RaspoHjpAejPt�o t@ 4.Manifest Tracking Number �� <br /> WASJE MAfJIFEBT <br /> 5 Generator s Name antl Mailing Address Generat r Site Address if different than mailing address) <br /> z =' F, riz �s 41 x, 13C,Irsr t fsT <br /> Ch 97 E'27 S f�a•{- t i3 10,"o, C,Sf ale <br /> a.3>a <br /> Generator's Phone: <br /> 6.jra��{{jr$potter 1 Corppa y ale t .y,r;• U.S.EPA ID Number i X�.l.?f!°,}f; - .,'.f.s`� <br /> 7.Transporter 2 Company Name VA.EPA ID Number --=7 <br /> 8.Designated Facility Name and Site Address s!,AHE 'Y.K EV r t =l' f , T r�'f;. U.S.EPA ID Number <br /> 6000 88TH EBTREAFT <br /> Facilitys Phone: <br /> ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.NOl- <br /> 1. t I_ <br /> t„ . .t;; € ( i:) $.1 Esr.K r•_ t ()ti r} <br /> A r;71 W A'Z_!J 0FQ f:0(.,L T 10 W, <br /> Z 2. <br /> UJI0 <br /> -, <br /> 1 04- <br /> 3. <br /> 4. <br /> 14:Special:Handlinglnstructions and Additional-Infoamation �`,,',,v',�,�,r- <br /> tjz taP I x ldr Mrd af)(f era f '*.oil =(J 2f € g J )) pr <br /> t.� fi O i4 �t t�! f tf �t)�",��'.2xtt�k/ � <br /> .. ,a>•_.v } ,.lar. d tt),.! r t�.£-t[^:y.i_ _ <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 andlabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and1hational 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 Conse <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 /asmall quantity generator)is true. <br /> Generator Jferors Pdntodfryped Name Signature Month Day Year <br /> 16 International Shipments ` t <br /> 2 . . a ,_ <br /> 4 Import to U.S.. Export from U S '. Pott of entryleicit <br /> ,- .. :? f Dale leaving t1,S.. <br /> Transporter signature(for exports only) t <br /> w 17.TrarisporterAdmowledgment of Receipt of Materials 1 <br /> 12 Transporter 1 Printedfryped Name Signature Month Day Year <br /> O�KAt <br /> o �atL. , <br /> ,05 <br /> N Month Da Year <br /> aTransporter 2Printed e�¢Name Signature .w y <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ElType ❑Residue s' El Partial Rejection <br /> Full Rejection <br /> a <br /> Manifest Reference Number. <br /> 18b.Aitemate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Facility-Phone <br /> W 18c,Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2E <br /> N 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> r- <br /> 20:Designated FacilityOwner or Operator Certification of r6;ipfof Hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature• I Month Day Year <br /> f! ( c <br /> IJ - 1 4 <br /> t 1 1 _ <br /> EPA Form 8700-22•(Rev,3 05) Previous editions are obs DESIGNATED FACILITY TO GENERATOR <br /> +ped 7_zll <br />