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CD OC:) (D <br /> --h _j -0- D <br /> v poor <br /> TI O O O O <br /> rn <br /> a � ww � o <br /> O w co co cn <br /> N N 3 <br /> M � wwM <br /> _ „p q O w r.) <br /> � �II <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ^^ � <br /> O <br /> UNIFORM HAZARDOUS I Generator ID Number r a v ••--- -.- -- - --- C I--- 00 (n <br /> WASTE MANIFEST i 1 1 3 9 2 8 1 2 F L E -.1 zt 3 (D <br /> ,en"mrs Name and Mailing Adlms,, <br /> 2 <br /> W 20- (D <br /> 00 w w O D <br /> Generators Phone'.I <br /> n Tmnspoder I Company Name CD <br /> ) 00CD <br /> 7 Trensponer2Compem Name w O <br /> OOCOC (D <br /> 8 Des a Facility Name and Site Redress UNumber.S EPA ID Nuer C) C) co � n <br /> f O w w Q v <br /> Facility's Phone: \J =3D <br /> ga 9b.U,S: f DescnpGon$eluding Proper Shipping Name.Hazard Class.ID Number, 10.Containers 17 TOWI 12 Unn <br /> W1 and Packinq Group ld anynOuanOty .. ... _ (D <br /> No TyVe :^/t^.'o: <br /> 11 <br /> 1 or <br /> I <br /> z <br /> CD <br /> D <br /> O <br /> r� <br /> O <br /> O <br /> 14 Special Handling Instructions and Additional Information r-h <br /> 0 <br /> I <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accufalely described above by the proper shiptung name am are classiee pawged <br /> marked and lab eleciptacarded,and are in all respects in proper condition for transport according to applicable international and national 9nvemmental regulations 11 expod shlprnent and I r foe P-rNn \,/ <br /> Exponer.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify!hal 1.waste mimmiration statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a sm t quantity generator[Is We. <br /> Generato ero s PAntetl ype ame Ignature (31 w <br /> CO 00 w <br /> —is <br /> H ❑moon to U.S , . (_n N W <br /> ip <br /> Trans Mems nature fa ex ds onl 081e leev US,'. w M Q <br /> W ll.Tr6ms'eter AckrgMedgment of Receiploi MBtehals N 00 CD <br /> Transporter 1 PNae nntedrTyped Nignature <br /> -- �- r r r <br /> z T n A !typeSignature 1 <br /> mmm <br /> Q i <br /> }I 18 Discrepancy w <br /> I <br /> 18a Discrepancy Indlcalion Space ❑Quantity ❑Type ❑Residue ❑Pamal Relernon U fyA O <br /> Manifest Reference Number: a) 00 00 <br /> 18b.Altemale Facility,for Generator) US EPA ID Numbih <br /> .4 <br /> LL ^ ^ ^ <br /> FaUlll s Phone: <br /> w 18;SynaNw WAllornale Fac161y for Generator) MorMt 1Yr <br /> z C) � � <br /> 19.Hazardous Waste Report Management Method Code,(,a,codes for huamdous wasle treatment,dKpnsal,and mcyllsey 4yslemsl � t� t� <br /> I <br /> 20.Deeignated Facility Owner orOperator Certification of receipt of hazardous materials covered uy Iho memrest except as n'ted in Ilan 18a n <br /> 1 PubtedRyped Name Slgualum <br /> I I I i; Q <br /> EPA Form 8700.22(Rev 3.06)Previous edlbons are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br /> (D <br /> CD <br /> O <br /> 0) <br /> CD <br /> v <br /> v <br />