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`-Pleat mt or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050.0039 <br />UNIFORM HAZARDOUS 1. Genarattw ID Number f 2. Pogo 1 of 3. Emergency Response Phone 4. Mani <br />fest Tracking <br />tNNu"mbber <br />WASTE MANIFEST t"f r' /L &-vsfr)11.5 /' ai' r ' %� 0 0 8 8 2 i 1 J F L E <br />5. Generator's Name -rid Mailing Address Generator's Site Address (it different than mailing address) <br />ej <br />'"SCJ/ 6 ��rz"."�,kr <br />Genera ot's Phone: <br />6. Transporter 1 Company Narrja JOT U.S. EEPtA ID Number <br />/ <br />Jon ."�Y ,til, !i!'l!)Xf �..f1 ee1 5" t:'! jP f7'f (_-�L'#�C'7 <br />7. Transporter 2 Company Name j - 1i' U.S, EPA ID Number <br />i0eri ii v Cr rr`� US.t'�;�rf �`)f <br />6. Designated Facility Name and Site Address f U.S. EPA ID Number <br />rr <br />Facili(ysPnoh�e'�fi�Y" j,�i/1' rte%rr..�j-/k)i:� <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, (0 Number, 10. Containers 11. Total 12; Unit 13, Waste Codes <br />HM andel Packing Group (if any)) / / No. Type Ouani ty WtNol. <br />1./ir/Tj, 1c�1L r!� j h j'1'C+'(C't:fJi G•',jj <br />re5p7 r ILA #1�1 , Pt i �' � f T J �� <br />w LLJ2 <br />P jIl[ 1 t/YI } <br />t <br />i <br />3. <br />4. 1 <br />14 Special Handling instructions and Additional Information <br />fr�� - y� 5 7le,/� C c f' <br />15, GENERATOR'SIOFFEROR'S CERTIFICATtON: I hereby declare that the contents of this consignment are fully and accurately described above by the prooar shipping name, and are classified, packaged, <br />marked and tabeledipiacarded, 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 (he attached EPAAcknatrledgmeni 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 />Ga ra!ar 5 erofs P1r gtdrTyped Name Oft D , i f_01 l? � � rc }r � jrgriati o )� �j � �c� � � � ojit ay a� <br />, . a�`..1 YtG if1, 61 1/Iti(1 rye `� c 'rw i tai �.� <br />_r 16. International Shiprfionts S <br />F— ❑ import to U.S. ❑ Export from U.S Port of entyl�f[:.. _,.__ _ ,__ ._ _ • _.__ <br />— Transpolar signature for exports only): Dale leaving U.S.: <br />W 17. TransporterAckmMedgment of Receipt of Materials <br />ll�Trans ` 1 n tad ped ignature e a ea <br />z Tr5nsp6rter2Pnnl6dd(Tjpedt�amaf)"? �r•! Ignaturet'� �,.—� (q IMonth Day Year <br />18. Discrepancy ,, <br />Ilia- Discrepancy indication Space t _I Quantity F] Type El R Sid re Partial Rejection Full Rejection <br />Manifest Reference Number. <br />I Bb. Alternate Facility (or Generator) U.S. EPA ID Number <br />U <br />�Q+ Facilit 's Phone: <br />µpi 1 Be. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />N19. Hazardous Waste Report Management Method Coles (La, codes for hazardous waste treatment, disposal, and recycling systems) <br />LLJ 1. 2, 3, 4 <br />20. Designated Facilily Owner or Operator Certification nLrficeipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedlTyped Name ( r Signature f r` y ! Month Day Year <br />/.j j, l "• i i l . ,� � .) �I _ .. ,�,;,�!,/� �_.,•�,.•-' w,,.( ��,r— �,,� ; fel f r-� <br />EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. r _ ' DESIGNATED FACILITY TO GENERATOR <br />