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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.20%0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �( <br /> WASTE MANIFEST t L ( tl ?t . u z),. ' '}w,'',>,j JJK <br /> 5.Generator's Name and Mailing Address Generator's Site Address(H different than mailigg address) <br /> 11f•l V 1-0-k OZ-fz-.' <br /> aatl t- KFI-i't.EA4a1M Rid <br /> Generator's Phone: <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 ID Number <br /> )i ,lig�,Oh <br /> 4xi U*VRO N WA <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(d any)) No. Type Quantity WtNol. 13.Waste Codes <br /> 1. <br /> 14(.4+ tW HAZARDOUS WA:3IE,LF"41_40(ALY'WA%R) <br /> z 2. <br /> LU <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> NAER'0* ;+ 1 1T 1 ^PROFILL#%l i'St1.I 10442 1&tR6 -X1`Y•-'()NACT !f AiPI-( I WCe.424-92M^Aroj,)3+'bNAL FPA <br /> CCUES +fit . N(*k.x:PPRC41RIArE P[:f;`O+Al PfdOIT--+✓TIVE-FCil_4f3tENT <br /> 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 /> marked and labeled/placarded.and are in all respects in proper condition for transport according to applicable inlemational 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> Generator's/Cfferoes PdntWyped Name Signature Month Day Year <br /> 16.International Shipments <br /> Z ❑import to U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name Signature Month Day Year <br /> O <br /> a <br /> N <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> h <br /> 18.Discrepancy <br /> i <br /> 18a.Discrepancy Indication SpaceQuan�y ❑Type Resicue <br /> ❑ ElPartialRejection ❑Full Rejection <br /> ❑ ' <br /> Manifest Reference Number. <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> V � <br /> ua Facility's Phone: <br /> LO 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL.COPY <br />