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Please print or type.(Farm designeflor use on elite' 12-pitchy rewriter.} Form Approved.OMB No.2050 039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Traddag'Number <br /> WASTE-MANIFEST €..�l�Ll�f 04:-J-_) L +�5{s :' i 01749 1 24 JJ K <br /> 5.Generator's Name and Mailing Address »IV"j Travel CM : Gen eratoesSteAdd re� d different than mailing address] <br /> !i5W Lovas Road <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number + , <br /> 'q ffo i e Has s•' emes-�`-. <br /> 7,Trawparter 2 Company Name U.S.GPA IU Number <br /> •a+ <br /> 0.Designated Facility Name and SiteAddnus: tI1G yr U.S.EPA ID Number <br /> C;k■� <br /> f Q <br /> Cra€*ow CA USA <br /> ga gb.U.S.DDT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.ConWners 11.TOW 12.Unit 13 vas Codes <br /> HM and Packing Group(d any)) No. Type Quantity NRNoI. <br /> a Ott 1<.'13 449 Ftarrttt�-:tom!'�tS,Pi.o.'+s (y''. TT C: DUO '1134 <br /> LU <br /> C7 <br /> 3. <br /> 4. <br /> 1 <br /> 1.Special Handling.lnstnrotions and Additional Information <br /> Weal fiq <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 and labeledlplacarded,and are in all respects in proper condition for transport nocording to applicable international and national governmental regulations.0 export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimi mfian statement idenGaed In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(f I am a small quantity 8e4rator)is true, <br /> GeneratufslOfferor's Printedffyped Name Signature Month Day Year . <br /> [ � .f G.----^.►.-.. <br /> Fij 16-International Shipments <br /> ❑import to U.S. ❑Export from U-S. Port of entrylexlG <br /> a Transporter signature(for exports only): Date leaving U-S.: <br /> 1Z 17.Transporter Aelmowtedgnrer t of Receipt of Materials <br /> Transporter 1 Nntedayped Dame Signature ' s fi Month Day Year <br /> CL <br /> Transporter 2 Pentedfryped Noma Signature A Month Day Year <br /> GC <br /> N <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity []Type ❑Residue ❑ParEiai Rejection ❑Full Rejection <br /> Man&at Reference Number- <br /> 18h.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> U- FaaliIA Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> z <br /> 1- -1.Hazardous Waste Report Management method Codes(k.e.,codes for hazardous waste treatment,disposal,and recycling systems] <br /> 4• <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> I'dntedlTyped dame;.,i ignahxa Month Day.. Year.. <br /> EPA Farm 8700-22(Rev.3-03) PreviDus editions are obsotete. TRANSPORTER'S COPY <br />