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Fleast print or-te.(Ford designed for use an elite(12-pltcld)typewriter.) m Approved.OMB No.2050-0039 <br /> . gEmergency 4.Manifest Tracking 2Pae 1 of 3 EmerRPhL— ; _ <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number cki 97 Number <br /> WASTE MANIFEST SO IS 91f Mrs <br /> 5.Generator's Name and Mailing Address 00 99R SK <br /> Generator's Site Address(If different than mailing address) <br /> Generator's Phone: r,Vi 1 jt <br /> 6 Transporter I Company Name US.EFA ID�Numbo, <br /> ru <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> 1 1 U.S.EPA D Number Y—FA f f]N IT [�At,I tirlid; v� <br /> FIEWORK Ft :?,l"1"0 <br /> Facility's Phone. I I , 11: <br /> IN 0,10 1'q I <br /> ad. go LLS.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM I and Packing Group(if ani No. Type Quantity Wt Ayol. 13.Waste Codes <br /> Pt l lihi- K Rr) t4 Q WOST R, L IPUID <br /> 2 <br /> ILL! <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information m'El I E k q 7 di Z., I it 7 c,15t%'- <br /> 1760, /.ISM <br /> L f�q�,tj I t; ral W41.I��c,t C v yt� f�Q� r,1grdr-e,,ov <br /> ,r, . t <br /> 15.�—��E�NE��f'O�"'5�i"OIFFEROR'SCERTIFICATIONi I hereby declare that the contents ofthk consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked andlabeled/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 cartily that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent L <br /> I oddly that the waste minimization statement identified in 40 CFR262.27(a)(if I am a large quantity generator)or d)(If I am a small quantity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name Signature <br /> March Day Year <br /> + <br /> —a 1611niernational Shipments <br /> p— 11 import to U.S. ❑Export from U 3 Pon of entry/exit: <br /> Transporter signature(for expels only): Date leaving U.S.: <br /> out 17 Transporter Acknowledgment of Receipt of Materials <br /> �2 —Iranspoqerl Primesollyped Name Signature <br /> 0 Month Day Year <br /> I ranspdrer 2< PrintemV I Ypea Name Signature <br /> Month Day Year <br /> IS Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity E:1 Type ❑Residue ❑Partial Rejection 1-1 Foll Rejection <br /> Manifest Reference bar <br /> 18d.Alternate Facility(or Generator) U.S.EPA ID Number <br /> D <br /> U <br /> LL Facility's Phone. <br /> Ow 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> !Zi <br /> Z <br /> 0 <br /> 55 19.Hazardous Waste Record Management Method Codes(Le„codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator:Codification of receipt of hazardous materials covered by the manifest except as noted In Item Ise <br /> Printed/Typed Name Signature Month <br /> Oay Year <br /> EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. <br /> h GENERATOR'S INITIAL COPY <br />