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In %l IT III <br /> IT I At <br /> Please print or t pe. <br /> UNIFORM HAZARDOUS 1 . Generator ID Number <br /> WASTE MANIFEST �a , 2. Page 1 of 3. Emeency Res once Phone Form Approved. OMB No. 2050-0039 <br /> �( tI dT1 IT -�..r ( " P 4 Man fest Tracking Number <br /> 5 Generator's Name and Mailing Address C _ �' ,tri 1 fl r - <br /> 'I 1� ) C" � i , { f ' > z 3 r Generator's Site Address (if different than mailing address) �� SKS <br /> L " tFt <br /> S ; ° ii ' , a '; . 1 1 z . �: _ 1 ' t6 € vpr' . <br /> t . . . <br /> l..l t <br /> Generators Phone: " int - , d%j -� , ? t 14 j =-1 <br /> 6 Transporter 1 Company Name <br /> U.S. EPA ID Number <br /> ITT 7. Transporter 2 Company Name i t .•'t+, t l ', if <br /> i. ; U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address j t { <br /> ax ; p £ <br /> f > b a (t 4 r t r 9 { le ITT <br /> tr` U.S. EPA ID Number <br /> r � : i k:, . ( t € <br /> + . <br /> r { j rt: � , 4 q <br /> Facility's Phone: <br /> t € tst liar,=i a /E2 'j 'i ;' <br /> ga• 9b. U'S DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br /> HM and Padang Group (if any)) <br /> 10. Containers 11 , Total <br /> r T e Quantic 12 Unit <br /> } , p t I IT,I t o I No YP y WtNol. t3• Waste Codes <br /> �{ t f <br /> r <br /> ' ( r <br /> wt� ITT, Tt <br /> j (JYfr r ! < t ( e t`f <br /> It <br /> I , ITT <br /> W 1 -4 <br /> 2' <br /> 0 <br /> 3. <br /> 4. ®d. <br /> 14. Special Handling Instructions and Additional Information <br /> r' . I .<_` ick s a ', I t. r <br /> ii <br /> i s t� ra is t . ��rt sa it s tl pIT <br /> Yt V It ITrr <br /> tY' + . � . .. . r . . , . . . ), l IT s e ( . ;, a € i s-' a .:. -, + 41. ! Asa - E 1 ? {' r IIT, T <br /> d ITT <br /> ill !? eft t , <br /> f . , . V l + Cir ' r� f3ti +nt 8 5; # it tf?€•� r � a {"Si • :'' ^w. €' tl Asa , r • '§ . e r ¢ + : -� l"s .�d I « .. <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnbeil above by the proper shipping name, and are classified, packaged, <br /> marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I cerfify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br /> Generator's/Offerors Printed/Typa Name Signature <br /> { 1. IT <br /> Month Day Year <br /> i/ <br /> .j 16. International Shipments - <br /> F ❑ Import to U.S. ❑ Export from U.S. ` Port of entry/exit: r <br /> Z Transporter signature (for exports only): Date leaving U.S.: id _: ` <br /> W17. TransIII - porterAcknowledgment of Receipt of Materials <br /> 6ETransporter 1 finmed/Iyped Name <br /> O Signature Month Day Year <br /> . ,.., <br /> lot <br /> Z Transporter 2 Printed/Typed NameITT - Signature Month Day3 Year <br /> H <br /> 18. Discrepancy <br /> I Discrepancy Indication Space <br /> Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID NumberNINE <br /> U <br /> � Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> Middleton <br /> z <br /> WHEN- <br /> W 19. Hazardous Waste Report Management Method Codes (Le., 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 1 Be <br /> Printed/Typed Name Signature Month Day Year <br /> =PA Form 8700d,22 (Rev, 12-17) Previous editions are obsolete. GENERATOR, IPS { { L COPY <br /> L ! ' <br /> .. fit t • <br />