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Please print or type.(Form designed for use on elite(12-pitch)type 'ter.) Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number � t 2.Pagel of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST fJ ' ,?1 i'f /,0 " q 0 7 ? 007P ­- J J K <br /> 5.Generator's NEe an¢Mailing Add1- Sress / Generator's Site Address(if different than mailing address) <br /> G /3 ox 23G 23 G S AIfd <br /> Generator's Phone: j :/f, 6 k- )7 S Z <br /> 6.Transporter 1 Company Name U.S.EPA 10 Number <br /> 7.Tr�sporter 2 ompany Name � � J U,S_EPA ID,Nu�r co <br /> 8,Designated Facility N4ne and Site Address C J A N y 8 2016 0, U,S.EPA ID NAN, <br /> CG r7G G l <br /> ? 3 A4fd/A�� rec/p�'J�14. r G J // <br /> �. L S tf LT ��� <br /> Facility's Phonp: - 7 ', S , _ _ 2 <br /> 909b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers � 11.Total 12.Unit <br /> HM and Packing Group(if any)' 13.Waste Codes <br /> No, Type Quantity W1.Nol, <br /> W " ,VA 3G 7 ) �r�v Pz��� �1� �d� Sa 1, ,A),' S <br /> i <br /> w 2' I� <br /> 3- <br /> 4. <br /> 14.Special Handling Instructions and Additional tnformaton <br /> 61 y svi 51 �rE� s� <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and aoauraWy described above by the proper shipping name,and are classified,packaged, <br /> marked and iabelecilpfacarded,and are in all respects In proper condition for transport according to applicable international and national governmental regulations,11i shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment confarm to the terms of the attached EPA Acknowledgmeni 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 true. <br /> GeneratoeslMroes Printed/Typed Name p Signature <br /> Month Day Year <br /> !i {f l4!1 F a'1 air' v 7 � <br /> 16.International Shipments <br /> I— ❑Import to U.S. E]Expert from U.S. Port of entrylexit <br /> Z <br /> Transporter signature(for experts only): Dale leaving U.S., <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> ii Transpo `1ntedlTyped Named fJf Signature Month Day Year <br /> Z Trans orter2Pnote dlTyped me Signa tyref M�onnth Dray (Yearn <br /> 41 <br /> 18.Discrepancy r !!/! <br /> 18a.Discrepancy Indication Space El Quantity ❑Type Residue❑ ❑partial Rejection ElFull Rejedion <br /> Manifest Reference Number: <br /> 18b Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> W Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(1,e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1' _ 2. 3. 4. <br /> 20.Designated Fatuity Owner or Operator Cerdeation of receipt of hazardous materials covered by the mahifest except as wed in I I Be <br /> PrintedlT pe¢tJ <br /> Signature <br /> Month Day <br /> jl c <br /> EPA Form 8700.22(Rev.3-05) Previous edwris are obsolete. DgIGNATED FACILITY TO GENERATOR <br />