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0 0 6 9 5 2 6 5 2 S K S <br /> Please print or type. Form Approved OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page of 3.Fmer�geq+c�Rers�o e.Proge.'4� 4.Manifest Track in N�u]mb[e�r,., (��/(� <br /> UNIFORM HAZARDOUS f:Ht ht7tdfc 2r� .r i t,4. s 10069 2 6' V KS <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 2 <br /> t rr c t it t: X301) W Hallr <br /> TIN 8 1 Il <br /> Generators Phone 0 € -788 <br /> 6.Trac, er l�qm nyA e U.S.EPA ID Number a1 'A.'z_°.�r <br /> r f r I � 5Y .TFM,9 ytj;'. TXR'000 Ft. a-yr- <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLiFAN H-1 <br /> 8,Designated Facility Name and Site Address � � j-1)'i rel;� q =,phi Tfl;moi.: U.S.EPA ID Number <br /> Facility's Phone, <br /> ga 9b.U.S.DOT Description(including Proper Shpping Name,.Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type ))Ouandty, Wit NoL <br /> O T I AU i,,R Fi <br /> z 2. <br /> 3. <br /> 4, <br /> 14 Special Handling Instructions and Additional Information <br /> r— s ,'s+i t " TFI--j-nru r r i <br /> } ,. ' ♦:±. „:,,+„ -rr it cw tit€hc; , r'n -�`_ <br /> 15. GENERATOR'SIOFFEROR'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 snnq labeledlplacarded.and are in all respects in proper condition for transport according to applicable international and national go omental regulations.If export shipment and I am,th#,Pdmary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. +- <br /> j cerhlythaf the waste minimization statement identified In 40 CFR 252.27(a)(if I am a large quantity generator)or(b)(ill am a small quantity generator)is true. <br /> GeneralEf - erorNPrinted yped Nam /y Signature Month D� Year <br /> C <br /> .2A jk�JW <br /> J 16.Intemena Ship <br /> F ❑Import to U.S. ❑Export horn U.S. Port of entrylexiY' <br /> ? Transporter signature(far exports only): Date leaving U.S.. <br /> K 17.Transporter Acknowledgment of Receipt of 103irtas <br /> OTran prt r 1 Printedlfyp Names - Signatur t Month i <br /> 11 1 3 <br /> to Signature - Month Day Year <br /> y n. <br /> Trans orter ZPrin d/Typed Name 9 <br /> Q <br /> tY <br /> H <br /> 17-1 <br /> 1 . isaeparcy <br /> 18a.Discrepancy Indication Space ❑Duantlty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> r 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> tai Facility's Phone: <br /> C3 18c.Signature ofAltemate Faciliity(or Generator) Month Day Year <br /> z -. <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,ruckfet hazardous waste treatment,dis 'and recycling�ys$9rd <br /> 0 1 2 3' 4. <br /> 20.Designated Facili n or enter.Cefi1`1 n of recei azardous materials covered by the manifest except as nded 18a Y <br /> Printedflyped Name Signature <br /> EPA Form 8700-22(Rev 12-1 lous editi ete. DESIGNATED FACILITY TO EPA's t-MANIFEST SYSTE <br />