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Please print or type.(Form designed for use on elite(12 pitch)typewriter.) <br /> UNIFORM HhXARDOUS 1.Generator ID Number Z Pagel of 3.Emer ency Response Phone, 4:ManifestTracking Number H, <br /> WASTANIFEST <br /> 1.tL. tf {1�ttia} 1J .► .,1#Ewt ""� rf V <br /> � � r - <br /> 5.GeWfators Name and <br /> /2Mailing <br /> [Address Generajto(fs SSitte Address j(iiff differren�t•than malting address) <br /> I� 1 }� •- tk l3 e4�.{t /� �.nd�S t<�r r"�Z.)L,y ! M�a <br /> tttlt•fS,aVol�� 1��chollr�y L8501 I !4r'�f 0x 1 .ori. <br /> t..'Ttald 7 { f1 C1tt'£! r�t = <br /> Generators Phone: � <br /> 6.Transporter 1 Cowan Name <br /> :zt`zj y._ L FN T MB, (r��'• U.S.EPA ID Number <br /> ' <br /> 7.Transpor#er 2 CoinpahAariie j: ( U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> t rl # 4N lvwxw (IF 14TLf41N6' fJN , 1 t <br /> [ a EAr? € #11'x' }t WE"I <br /> Facility's Phone: <br /> ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,yD Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1 it;...)`l fir) <br /> z 2. <br /> W <br /> U) <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information Y 2t g i '1361 <br /> rg 9 0D <br /> t <br /> „r468...176 (SK i F <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the CogtentsnEthis conslgnipent are filly And accurately describedabovo by the proper shlpp(ng.name;and are classified,.P at�taged, .. . <br /> marked and labeledfpladarded;and am In'all pe'cts in ptoper cohdition fol transport accordingto applicable intematlo-it and national go4emmenial 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 ani a large quantity generalo0)(if I am a small quantity`a rator)is e. <br /> Generator'slOfferors Printed/Typed Nam. i nat e <br /> , ,. 9 t� Month Day Year <br /> '> rX t 't t /fj1 e�.t 44Vr <br /> --r16.International shipments ❑Import to U.S. 0 Export from U,S. Port of entry/zit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name i Signature Month Day Year <br /> U3 <br /> Transporter 2 PnntedfTyped Name Signature *.. <br /> •- r C Month Day Year <br /> 1$.Dtcrepancy r,. <br /> 18a`DtsdrapanTh'd(cAtionpGe ;:Ouantity } 1 Rasitf t p <br /> Y1#e tf? % O <br /> FullR <br /> Pattial'Re1eC8on ete n <br /> Manffesk fereriee Number <br /> 18b Aitemate Facility(or Generator) S.EPA ID:Number . . <br /> 2. FacilitysPhone: <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment;dill set,and recycling systems) <br /> D 1 <br /> 2. <br /> 3• 4. <br /> 20.Designated Facility 04vner pr Oge[ater:Certifioatiaq of;tecelpt:pf Oazardousmaterialscovered by the man'rfesf e>Zcept as noted in item 18a <br /> PnntedRyped Name signature <br /> / T,r_ 9 ? Month Day Year <br /> EPA Form 8700-22(Rev.1_413-05) Previous editions are obso e• DESIGNATED FACILITY TO GENERATOR <br />