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Please print or type. Form designed:.for use on elite(12=pitch)typewriter, Form Approved.OMB No.2050-0039 <br /> Fj <br /> FUNIFORIA HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking NurntferWASTE MAHkFE37CA # i. 14: } �i.}�1 dti4- i174� �. ' JJK <br /> S.Generator's Name and Mailing Address ?i 'mss? 1 Generators Site Address(if different than mailing address) <br /> = Tf?riri3i ^ ° ) <br /> 345 flx*h Rd <br /> Generatoes Phone <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ti;fd+pit a Fla meows 3erw.el#ttC <br /> 7,Transporter 2 Company Name U-S-EPA Ip Number <br /> 8.Designated Fadlily Mame and Site Address.. ._ r U-S-EPA ID Number <br /> i 6'iQ . 111h; <br /> s-0ima"Cf1.ti:A w'r*,14 LI-a+_ <br /> Facility's:Phona: <br /> ga. 9b.U.S.DOT Description(kfcfuding Proper Shipping Name,hazard Class,ID Number, 10.Containers it:Total 12.Unit <br /> HM. and Paddng Group('d any)) 13.Waste Codes. <br /> No. Type Quantity ►hR.lVat. <br /> 1. <br /> p �,'r=` ..�'-TE 501 iL. f <br /> W � � <br /> LU <br /> LU <br /> s <br /> 3. • <br /> i <br /> 4. + <br /> 4.Special Ff)andtirgllr�3ructions�ndAddiNonal Ento(rnatfon. <br /> 15• GENERATOR'SlOFFEROR'S CERTIFICATION: €hereby declare that the contents of this consignment are fully and accurately described above by the proper shlppfrg name,and are classified-padmpd, <br /> marked and tabeledlplacarded,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 oonlents of ibis consignment conform to the terms of the attached EPA Admowledgment of Consent <br /> I cortlfy that the waste minimization.statement identified In 40 CFR 25227(a)(if I am a large quantity generalor)or(b)(if t am a small quant ty generator}is true. <br /> Generatoep/OHeror's PrintedlTyped Name Signature Month Day Year <br /> -i to.International Shlprreerils <br /> i:— ❑lrr rtto U.S. ❑Export from UZ. Port of entrylexk: <br /> Transporter signature(for e)rpmrts only): Date Teaving U.S.: <br /> K' 17.TransporterAcknowledgment of Recalpt of Materiae. <br /> Transporter 1 PrintedlTypedlVame Signature i Mom Day Year.. <br /> J— <br /> CL E. rA f' w....._. <br /> ii i P ., .f,-.. <br /> Q Transporter 2 Printedffyped Name SISIMIUM Month Day Year <br /> fr ' <br /> F <br /> 18.Discrepancy IIi�iI <br /> 16a,Discrepancy ITld1ca6on Space ❑Q.thy ❑Type ❑Residue LJ Partial FWXOon ❑Full Re.A. <br /> MwifestRelarence Nw6w. <br /> t8b.Alternate Facility(or Generator) U.S.EPA ID Number . <br /> U <br /> LL Facility's Phone: <br /> LU 18c.StgnaWre of Attemate Facility(or Generator) Month Day Year <br /> a <br /> x <br /> I.Hazardous UVaste Report Management Method Codes(i.e.,codes for hazardous waste trealtnent disposal,and recycling systems) <br /> 2. 3. 4. <br /> 20.Designated Fadity Owner or Operator pettitio�tien of recalpt of hazardous paterials covered by the manifest except as nefad in Item 16a - <br /> PrInWr7yped Name e. �. Signature Month day year, <br /> EPA Form$700.22{Rev-3-q Previous editions are obsolete. . i TRANSPORTER'S COPY <br />