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10. Containers <br />No <br />Please print or type. (Form designed for use on elite (12-pitch) typewriter.) <br />UNIFORM HAZARDOUS I. Generator ID Number A <br />8. Designated Facility Name and Site Address <br />tIL 60 f,0,3 RVI dt. vie (-5 //(' <br />-INVIctS Lirl\fl(DAWAJOA_ lEgunge 2(172Q‘ <br />7. Transporter 2 Company Name <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />ilt °63/ 026)//tC`fdt o 003537417 G B F WASTE MANIFEST <br />5GeneraMPen"YpWo (i Mae ei 4-4/ad clizezt--- , V7? ,2-04) -II/ Ne)77)52 57--attrrN C4T 2e) <br /> 7eL -/J c <br />2 Pfr norm Approved. OMB No. 2050-0C of 3. Emergency Response Phone 4. Manifest Tracking Number <br />Genera or's site Address (if different than mailing address) . ,... <br />U.S. EPA I Number <br />I r I a)() /2/ <br />39 <br />(,‘Jvco'cIl\o-nck:\ <br />k_Lt\rilncks-k-r-koLx R-itaoixog-ris 0390_0(- <br />U.S EPA ID Number <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />koo taA iitiwun 5 KifVoE .D1,1 0 <br />3 <br />4 <br />14. Special Special Handling Instructions and Additional Information <br />66' <br />9a <br />NM <br />1 <br />2 <br />Type <br />11 Total <br />Quantity <br />5-64) <br />12. Unit <br />VVI Nol <br />15)— <br />13 Waste Codes <br />Ce 17 Transporter Acknowledgment of Receipt of Materials <br />b1/4 43‘..Ct <br />GENERATOR'SIOFFEROR'S CERTIFICATION: thereby 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 lam a large quantity generator) Or (b) (if I am a small quantity generator) is true. <br />Genera/t5sIffie4o,ry'elMed Name 5,74 <br />International Shipments LI Import to U.S. <br />Transporter signature (for exports only): <br />ElExport rom U S Port of entry/exit: <br />Date leaving U.S.: <br /> <br />Signature Day year <br />-J r- <br />ce <br />TranspxrIrktekiypiZ <br />0 I - <br />Tr nsporter 2 Printed/Typed Name <br />\N->ameArvA\ <br />18. Discrepancy <br />3Vi MZTit <br />Signatu Year <br />I I Signature Month Day Year <br />lUrUL6IsttAnkiiith.0 lstl. I Utbll,NA I tl) I-AGILITY 1 <br />Discrepancy Indication Space 0 Quantity E Type Residue <br />Manifest Reference Number: <br />El Partial Rejection 111 Full Rejection <br /> <br />Alternate Facility (or Generator') <br /> <br />U.S. EPA ID Number <br />Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br />,L(\ <br />Facility's Phone: <br />Signature of Alternate Facility (or Generator) <br />2 3 4. <br />ros- T3A Form 8700-22 (RA,' 1-05l Previous editions are ok,01,,,, <br />.1..., <br />20. Designated Facility qwner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature (..11v...1_ A/ Month Day Year <br />I LC I I IC/7)- <br />DESIGNATEDICILITY TO DESTINATION STATE (IF REQUIRED