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le se'forintbr type.(Form designed for use on elile(12-pitch)typevvriler.y':'�I,E,0.1`4-'� PfIVY Form Approved.OMB No.2050-0039 <br /> .502 iDfl/" - — <br /> UNIFORM HAZARDOUS I i.Generator ID Number 2.Page I of 3.Emergency Response Phone 14.MAnIfost Tracking Number <br /> WASTE MANIFEST 6 1)C. 7C#14 A,t I i'f 1 -7 Z FLE <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Lw i1i;op f.fit Gr' <br /> ti J? Avemie <br /> Generators Phone: ;14. 74t A'I <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 10 Number <br /> (Pat,il..it kir�,0 V k1mvillow, _J <br /> r. <br /> it <br /> ya glo.U.S.DOT Descriplion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers At-Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. <br /> 0 RA H A ZAP%U00 WA S TF. )1.J I-kl J.1-1 I..y <br /> ui <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <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 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[hat the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity geqqqtqr)or(b)Jif I am a small quantity generator)is tare. <br /> 9eneratofs101ferors PrnledfTyped Name Signature on Day leear, <br /> 16.International Shipments <br /> 1:1 Import to U.S. ❑Export from U.S. Pori of entrylexil: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> UW 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporler 1 Printedfryped Name Signature ---PITntR- Day —7ear <br /> 0 <br /> CL <br /> Transporter 2 PrinlerifTyped Name Signature MonIq Day Year <br /> IX <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Spam El Quantity E]Type 1:1 Residue ElPartial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Gerieralor) U.S.EPA 10 Number <br /> IJ- Facility's Phone: <br /> 0 <br /> UJ 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e,,codes for hazardous waste trealmeril,disposal,and recycling systems) <br /> C3 <br /> LIJ 1. 2. 3, T- <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Ilern 18a <br /> Prinledi7yped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> ,Ai�ap-"Arhov�hm <br />