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Form Approved.DMB No.2050-0039 <br /> PleFWASTra <br /> rit or type.(Form designed for use on elite(92-pitch)typewr�er.} �.Pie 1 of 3. <br /> Emergency Response <br /> Phone 4.ManiFgt Tra�ktng Nusr"ber J l �( <br /> ORM NAI.ARDOUS t.Generator to Number _ 0-1 7 4 9 1 3 4 .V J ■ <br /> MANIFEST •' -'+� <br /> 1 - Generators Site Address(if different than mailing address] <br /> Gensratoes Name and Mailing Addiess z.. ••:, ,!'rvW_F� g <br /> i M0 a 1!?fif i Vki"16- 1t%Thi$ <br /> 51W� : rates Rood ..45 W�14e1, <br /> Generatat's Phone: U.S.EPA 1D Number AR00 0 ; - <br /> 6.Transporterl Company Name frrsts3Pdit `s�3vis:e fnc . <br /> U.S.EPA ID Nunlher <br /> T.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> S.Designated Facility Name and Srta Address , .° rtfiig BzyyC .fttFQ :. <br /> 21JU]WiTh ft 's ItA <br /> CA 9022",2 UGA <br /> Facility's Phone: ' .9..7�(1r7` <br /> 9h,U.8:DOT Description(krchtding Proper Shipping Name,Hazard Class,ID Number, N Containers 11.Total 12,Linn 13.Waste Codes <br /> HM and Packing Group(4any)) No. Type Ruanfiry w OI' <br /> �y 2. - -- ---.... <br /> LU <br /> 3. <br /> 4. } r <br /> ;.Special Handling InStructiOnS>a[td Additional Information <br /> 15- GENERATOR'S10FFERDR'S CERTIFICATION:lHereby dedarethat she contents of this consignment are fully and accurately described above by the proper shopping name,and are classified,packaged, <br /> marked and labeledfplacarded,and are in oil respects in proper wr difion for transport according to applicable international and national governmental regulations,ff export shipment and i am the Primary <br /> Exporter,l certify that the contents of chis consignment conform to the terms of the attached EPAAcfmowiedgmant of Consent. <br /> I cetilfy that the waste minlmirationstatement identified in 40 CFR 262.27(a)(it 1 am a large quantity generator)or(b)(If l am a small quantity generator)is true: Month Day Year <br /> Generatodsli3lferars PrintedCfypad Name. Signature __ •_- <br /> J 16.Intemattonal Shipments Import la U.S. ❑Export from U-S. Part of entryfexlt: . <br /> date leaving U.S.: <br /> Transporter signstm(for exports only}: <br /> W1T.Transporter Acknowledgment of Receipt of Materials Month Day Year... <br /> w Signature <br /> Transporter 1 PriniediTyped Name <br /> N Signawre y�', Month Day Year <br /> 4 Transporter 2 PrintadlTyped Name <br /> A1C <br /> r" <br /> 18.Discrepancy <br /> ❑ <br /> 18a-Discrepancy Ir�dicattan Space � Quantity sidu <br /> Type ❑Ree ❑Partial Rejection ❑Full Rejection <br /> Manifest Refarenoa Number.- <br /> U S.EPA ID Number <br /> 18b.Alternate radRy(or Generator} <br /> J <br /> 5 <br /> tai Facility's Phone: Month Day Year <br /> tC3yyGenerator) <br /> 18c.Slgnatura of im ate Faculty(or <br /> i.Hazardous Waste Report Management Method Codes(I-e-,codes for hazardous waste treatment,dispos@t,and raoyclirtg systems) <br /> 3. 4 <br /> 2. <br /> � f <br /> 211.Designated Farality Owner or Operator.Ceriificat an of receipt of hazardous materials covered by the magifest except as Holed in Item 18a Year <br /> SignatureI -2 <br /> rintedfrypedNat�e <br /> 1_'•r !}� ]Irk' <br /> .r TRANSPORl'ER'S COP) <br /> EPA Form 8700-22(Reny:3-05) Previous editions are Obsolete- <br />