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Be Print or type. Form desi ned for•use on elite.72=ifah ewriter. ;' Form A roved:OMB No.2050-0039' <br /> ray UNIFORM HAZARDOUS WASTE MANIFEST 21:'GenelIraloDtNtu��myylie .' g 22 age-' 23.Manifest7racking Number <br /> (Continuation Sheet) ' 10.CJS 4�q l! Old 0[7 116 5 �I< <br /> 24,Generalor's Na <br /> �?(� n"'),►A <br /> 25.Transporter Company Name <br /> U.S.EPA ID Number <br /> U.S.EPA ID Number <br /> 28. Transporter Company Name.. . <br /> 27a. 27b.U.S.DOT Description(induding Proper Shipping Name,Hazard Class,Id Number, 28.Containers 29.Total 30.Unit 31.Waste Codes <br /> HM and Packing Group(if any)) No. Type quantity WLIVoI. <br /> Uro <br /> 557 <br /> 32.S' daI Handling Instructions and Additional Informs on <br /> � 5,K30 I� 3fr <br /> a 33.Tiaras iter AdmWed ment of Recei t of Materials <br /> Lu PnntedrFyped Name Signature Month Day Year <br /> sr <br /> O <br /> Q <br /> 34.Tmngporter AdmWed ment of Receipt of Materials <br /> r 3'5ri.ntedlTypedName , ,. ., .. . .._. -- ,r. . ... .. .... . �. <br /> Month... . ay .. <br /> e <br /> Discrepancy ar <br /> F <br /> U <br /> L¢t <br /> G ' <br /> u! <br /> Q 36.H rd Waste Re rt Management Method Codes '.e.)codes far hazardous waste treatment,disposal,and recyding systems) <br /> �t <br /> f=PA Form 87-M-22A(Rev,3705) Previous.etlilions are alisaleke.: :.:..,: [} 53GNACEO.FACILITY TO GENERATOR <br />