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cdlhlkhr 41 <br /> Please print or type. Form Approved.OMB No:2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3..Emergency Response:Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 0 a -0.3 FLE <br /> 5,Generator [amefand•M3iling Addles la S'7Ca14 Generators Site Address('rF different than mailing address) <br /> Jim <br /> Generator's Phone:M Dri77 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> tears I1 arlaolm EnvironmeaalSo vines.im. 41 A 0 0; ''3 0 <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 /> fs):ems Harbors Arap!oniste LLQ <br /> 1 a. :> rri NotthA'atus Read <br /> tar• nmvilfe.1JT U-101,29 <br /> Facility's Phone: M 15)S84-0100 <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(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> L4 S <br /> Df?iC t+.1.Fla 11 47011 p <br /> L <br /> X <br /> 3. <br /> 4. <br /> 1 <br /> 14.Spegial,Handlirlg°Jnptructions and Adgitippal:Infargjation <br /> %�ifttf3it r�t�Iniafl t►*�f`rf1�r�#�;=r c::s<i�ry:3<7�'t�t <br /> �t•:rr�rat„r� Int ni#P:�Pl��r:sti�ii?ff+��'tnt�.nr..,,�rrva�P+tAf1c�,,:,r �+�t <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 international 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 EPA Acknowledgment 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)(VV, small antity generatW�is true. <br /> Ge er tor's/Offeror's Printed/Ty ed Name Signature Month Day Year <br /> 16.Internatio a1'Shipmehts <br /> P- ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> z <br /> Transporter 2PrintedlTypedName Signature` a%»w' Month Day Year <br /> Q <br /> f- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity. ❑Type ❑Residue Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL 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(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 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 /> I ( rk,.d typed Name Signature Month Day Year <br /> EPA Form-8700.22�Rev."12.17)':Pr viotfseditions are otisolete:n�? 7 GENERATOR'S INITIAL COPY <br />