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Please print or type. - r - Form Approved, OMB No. 2050-0039
<br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2 Page 1 of 3. Emergency Response Phone4 Manifest Tracking Number _
<br /> WASTE MANIFEST CALL IL9> .X T,i .. e- 2�8 �c _� � 1 ,y7 1111 "JJ K
<br /> ',. Generators Name and Mailing Address - Generator's Site Address (If different than mailing address)
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<br /> Generator's Phoda 3FIFY0 "- IO'b C . 61t.0 a 9, Q�„ 20 _
<br /> 6. Transporter 1 Company Name U.S. EPA ID Number
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<br /> 7. Transporter 2 Company Name U.S. EPA ID Number S
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<br /> - '8. Designated Facility Name and Site Address t U.S. EPA ID Number I IF 1 11 IF.
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<br /> Facility's Phone(7 r T 7k '. -
<br /> ga, 91b. US; DOT Description (Including Proper Shipping Name; Heard, Class: ID Number, 10. Containers . 11. Total 12, Unit 13. Waste Codes
<br /> HM and Packing Group any)) No. Type - Quantity wt.Nol.
<br /> 1
<br /> 00 11 IY!A` G'(Z IIFIA7.P4 09,D SVyAr ,: TC SOLE,')) lvq,v'ti. >„ Ss, P(Ath,, t?ASOLIAS Ii Oil �E40 P
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<br /> UFA
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<br /> 4
<br /> i:4. Special Handling Instructions and Additional Information -
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<br /> S4,0Mt)CA -
<br /> = 15: GENERATOR'S/OFFEROR'SCERTIFICATION:them6.yAedareNatlheconlenls of this consignmentareioity-and-accurately described above bylhei proper Shipping name, andareIrlassifiedipackag€d, ----
<br /> marked
<br /> -marked and labeled/placarded,and main all respects In proper condition for transport according to applicable inteinationaland national governmental regulations. If expod shipment and l am the Primary;
<br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I ..
<br /> I redly that the waste minimization statement Idengfed In 40 CFR 262.27(a) (if i am a large quantity generator) or (b) (if l am a small quantity generator) is two.
<br /> Generptor'slOfe��s Pdnloulf” ed Name - Signatyre r ,_ , < M th ,,, o1F,
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<br /> 16. International Shipments r -
<br /> F I ❑ Import to U.S. ❑ Expert from US. Per of enlrylexit:
<br /> ? Transporter signature (far exports only): - Date leaving U.S:
<br /> W17. TransporterAcknowledgment of Receipt of Materials
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<br /> ' 18a Diserepanpy lndicatien Space ❑ quantity ' ❑N. Type ❑ Residee � I---I
<br /> Padal Rejection ❑`Full Rejection
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<br /> EM N, 00%
<br /> Number:
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<br /> let, Alternate Facility (or Generator) 13. EPAID Number
<br /> has the apps-ppi-iate permits (is
<br /> ra+. FacilllyxsPhone: for , and will aC ceO the waste
<br /> 18c. Signature of Alternate (or Generator) Month Dai, Year
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<br /> i9. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br /> 4. .
<br /> IF
<br /> 20, Designated Facility Owner or rentor: Certlfeaon of receipt of hazardous materials covered by the manifest except as IF In Item 78a -
<br /> PdntedlTyped Name ✓ ,,�' , - / Signature / i t t Month Day/ Year
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<br /> EPA Form 8700-22 (ReG. 12-11) Previous editions are o�sdlete. ' —"'"' - e!/Q N' GNATI D FACILITY TO GENERATOR
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