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lease'printbr type.(Form designed for use on elite(12-pitch)typewritery'-- I C,4-'x.502.0t)"(1 IV. Milk-7 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS <br /> 1,Generator ID Number 2.Page i at 3.Emergency Response Phone 4.M:qIfqst Tracking Number <br /> WASTE MANIFEST <br /> U <br /> FLE <br /> ! 'K I 'I UU <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than Ire III address) <br /> Generators Phone: r-iA. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Norm U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> ILW-'�t P.-Afni-S R oml <br /> ga. 9b.U.S.DOT Descriplion(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containe s 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. <br /> 2. <br /> W <br /> 3. <br /> 4, <br /> 14,Special Handling Instruckns and Additional Information <br /> 15, GEN ERATOR'SIOIFFEROR'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 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 EPA Acknowledgment of Consent. <br /> I certify[hat the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)('d I am a small quantity generator)is true. <br /> GeneratoesJOfferor's PrinledtTyped Name SigQature. <br /> on Day, Yegr <br /> =-j 16.International Shipments <br /> 1:1 Import 10 U.S. El Export from U.S'.- Porl of entrylexit: <br /> Transporter signature for experts only): Dale leaving U.S.: <br /> Lcr- 17.Transporter Acknowledgment of Receipt of Materials <br /> U <br /> Transr lar 1 PdriledlTyped Name Signature Month Day^+ ea <br /> 0 <br /> IL )19 <br /> (n <br /> M Transporter 2 Pfiniedrryped Name Signature Month Wy Year <br /> W <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 1:1 Quantity 0T ❑F-1 Residue ❑D Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 181b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> _3 <br /> LL Facility's Phone: <br /> C3 <br /> LIJ Signature ofAllernale Facility(orGeneralor) Month Day Year <br /> 0 <br /> r, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Ch LLJ 1. 1 3. 4. <br /> 20.Designated Facility Owner orOperalor:Certification of receipt of hazardous ma&als covered by the manifest except as noted in Item 18a <br /> Printed[Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> r(toVi 41 a4 I ht- is P m o iii dw o i fmt�it)6 a o it w%i 1) j o 4v rpt I b e i f.A{ u oat im'ir i 5 41 iil}l I a rs <br />