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/ le-A/AT 4,J /74--:- <br />if iv e-,1 ,t/ VI ?"2/0 <br />Facility's Phone: 911-- 5-25- - 0 <br />12. Unit <br />Wt.Nol, 13 Waste Codes <br />Signature4.}7( Month Day Year <br />I 5— <br />ElExport from U.S Port of entry/exit: <br />Date leaving U.S.: <br />Signature \i/ <br />Month Day Year <br />_)--1 (t, I t <br />Moth Day Year <br />Z-CIZ <br />Please print or type. <br />7 C4 1 Aer /A1116--) / 51tZ -22-0 <br />VIY;(4•14-05 4 3o bc .2_ 877 - 577- <br />WASTE MANIFEST 440a) 3 —776 5. Geperator's Name end Matting Address ‘. <br />UNIFORM HAZARDOUS 12yerator ID Number 2. Page 1 of <br />Eos <br />1-7.2 F <br />Form Approved. OMB No. 2050-0039 <br />4. Manifest Tracking Number <br />006457144 GBF <br />PCLO 41c <br />96--;24c; <br />3 Emergency Response Phone <br />'77 ,-517 <br />enerator's Site Address (iitfe)feren,et),an7iling address) <br />t 44,./zi <br />Transporter 2 Zmpany Name <br />, <br />U.S. EPA ID Number <br />OK <br />7. <br />\ <br />Fr <br />Nid' ekvitto.) -AA_ • s\?tibikV45--S <br />5t..-Ettsignated Facility Name and Site Address <br />U.S. EPA ID Number <br />;2)5 4/-ez:.)7,4,,06 <br />ii <br />6. Transporter 1 Cof ny Name <br />(Th\ ot \z\ vt, (A; ivvmsoco \Ao clz <br />_ON <br />U.S. EPA ID Number <br />I r-i\JI)1C'Ot (SN3c <br />9a. <br />HM GENERATOR 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />ON /F‘ 3 W. 5Ie 0-71447 je <br />Al" 9,3 v /I ZI,E,L, I 0e, tc' ( 14//i <br />2 <br />No. <br />10. Containers <br />Type <br />11 Total <br />Quantity <br />C <br />041) <br />3 <br />4 <br />14. Special Handling Instructions and Additional Information <br />--cs- <br />(i) <br /> <br />/V4 L /& $ —.7 3 <br /> <br />tk) 1/ 3 e I 15 GENERATOR'StOFFEROR'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 labeled/placarded, 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 contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify 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 />Generators/Offeror's Printed/Typed Name <br />fri4ljee1/ z—olky‘' 7-C <br />16. International Shipments <br />Import to U.S. <br />Transporter signature (for exports only): <br />17. Transporter Acknowledgment of Receipt of Materials <br />T s t.ler Printedrfyped <br />/IAA AA. <br />18 Discrepancy <br />porter 1 PrintediTypt Name <br />6 <br />j <br />MA/1 <br />1 <br />Discrepancy Indication Space Quantity LI Type LI Residue <br />Manifest Reference Number: <br />D Partial Rejection Ei Full Rejection <br /> <br />Alternate Facility (or Generator) <br /> <br />U.S. EPA ID Number <br />Facility's Phone: <br />19, Hazardous Waste Report Management Method Codes (i.e ,codes for hazardous waste treatment, disposal, and recycling systems) <br />2 <br />Month Day Year <br />IC% 1 610.2_ <br />DESIGNA <br />FACILITY TO EPA's e-MANIFEST SYST M DESIGNATED FACILITY Signature of Alternate Facility (or Generator) <br />Month Day Year <br />EPA Form 8700-22 (Rev. 12-17) Previous edi are obsolete. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest ex t as ncte Item 18a <br />PrZ4) <br />ped Name ean <br />3 4. TRANSPORTER