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rucvoma 1`11"' ul type . (corm designed for use on elite ( 12-pitch) typewriter.) <br /> ^ UNIFORMHAZARDOUs I , GeneratorlDNumber <br /> WASTE MANIFEST Form Approved. 0618 No . 2050-0059 <br /> C /A I ` , � 4 Iq j6 / 2 Page 1 of . Emeeiq ncyyRRe-sspoo�nse-Phone <br /> / 4. Manliest Trackin Number <br /> 5. Generators Name and Mapil:'�njg ddress j5 6 , + i GC+ (�� 015 2 �l 2 7 0 8 JJ K <br /> "-` < '[n ! <br /> t uz ,��Generale s;; SiteAddress (if different than mailing <br /> —address) <br /> a � IbI�S �^ llINV <br /> L � ti <br /> C) Generator's Phone: w _ �.� � G r ,—, / <br /> ccj6. Transporter 1 Company Name *� S � GGq J J i (o <br /> � `v t U.S. EPA ID Number <br /> U 7. Transporter 2 Company Name I I t� fi� <br /> . m <br /> .) I ( <br /> tD <br /> EPA ID Number <br /> 8. Designated Fac ili {Jaant{ Site Address <br /> 11 (n C'AjTU .S. EPA ID Number <br /> z (J15'I 7%Z, L 1 c <br /> Facihiy'sPhone: C � 1. , k� IQV ��� U � � 6 1�jV1 c�Aazi 5 �7 � <br /> 9a. 9b. U.S . DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br /> 5 HM and Packing Group (if any)) 10. Containers 11 . Total 12 Unit <br /> 1 No. Type Quantity Wt.Nol. 13. Waste Codes <br /> � <br /> o � 1gg3 W7�5 n � L► q � �1�s , � s <br /> b g it <br /> a W j <br /> c W 2. <br /> a` U' <br /> u <br /> Y m 3p <br /> m <br /> m <br /> N <br /> 4 . <br /> m <br /> O <br /> O 1 <br /> m <br /> U) 14. Special Handling Instructions and Additional Information <br /> i m <br /> c � <br /> m <br /> Z <br /> p ' 15. GENERATOR'S/OFFEROR'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 /> z 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 /> w 1 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowl gment of Consent. <br /> r I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity gene(Nor) or (b) (if I am a small quantity generator) is We . <br /> o G erator's e /TypedIN�me C*� 1 (J C' � Sig t re __ _ __—_ _ Month Day Year <br /> �1� S,� fzyG/cep 2 'T <br /> a 16 temational Shipments <br /> L <br /> [(n <br /> ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br /> Trans orter si nature for ex orts onlw P 9 ( P y) Date leaving U.S.: <br /> i7. TransporterAcknovAedgment of Receipt of Materials <br /> ' Tra po ter l P 'nI d/Typed Name C1 * i clvv_ c G - Sig re Month Da Year <br /> Z � � <br /> Transporter 2 Prmted/Typed Name Signa re Month Day Year <br /> 18. Discrepancy <br /> kSignature <br /> iscrepancy Indication Space ❑ quantity ❑ Type j 1 <br /> Residue Partial Rejection El Rejection <br /> Manifest Reference Number: <br /> t Facility (or Generator) U.S. EPA ID Number <br /> I <br /> s Phone: <br /> LOnature of Alternate Facility (or Generator) Month Day Year <br /> ardous Waste Report Management Method Codes (i.e. , codes for hazardous waste treatment, disposal, and recycling systems) <br /> 2, 3,gnated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> ypedName Signature Month Day Yea <br /> EPA Forn18700.22 (Rev. 3-05) Previous editions are obsolete . DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRE <br />