|
•
<br />Please orint or lvtje. Form Approved. OMB No. 2050-0039
<br />.- UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />I 1. Generator ID Number
<br />Generator's Name and Mailing Address , Generators Site Address (if different than m
<br />4a.iliMnganaldfedsretsTsr)ackIng 2. Page 1 of 3. Emergency Response Phone Number
<br />
<br />''' r.' ' ° 4 9 3 I, 2 JJK - ..‹. ,.....) ..- ..,, .
<br />...4.-- !•;f1 .1 !I:Wei t 1•1'.;',-, t klittr,t(6 '.. ,toti 7 ,
<br />.• '''. I OtIft4.-. kf,”tft
<br />6rdireikti.. III -4/1,114, 1.4:..11-4 . . v...111,; s.
<br />Generators Phone:- I
<br />Transporter 1 Company Name . U.S. EPA ID Number
<br />I
<br />Transporter 2 Company Name U.S. EPA ID Number
<br />I
<br />Designated Facility Name and Site Address U.S. EPA ID Number
<br />'''Tostly A OVet4011 in,:
<br />1,63(1 W. 11#1:k r ,,, ,
<br />1 ar,er t-cermh- i :1\ ;4tu-cl
<br />Facility's Phone: I
<br />Ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes
<br />HM and Packing Group (if any)) No. Type Quantity Wt.Nol.
<br />te
<br />0
<br />
<br />g Lu
<br />, I../
<br />Z
<br />LI
<br />
<br />
<br />
<br />p4. Special Handling Instructions and Additional Information
<br />1 t r Aly t tilt" s ikri.,,ottxtti,, flog': I Att.:1•• 1-4Taftse ki.r!),/: r ... Lrve.r.:11 i'm vtrapersire =, ..trmilkormo,a100,
<br />(1, 2 ztleict 3
<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, at 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) (ill am a small quantity generator) is true.
<br />y
<br />
<br />Generators/Offerors Printed/Typed Name Signature Month Day Year
<br />.....--_-_-.."--.......-........---
<br />.1 . i.,.._.1 '/. ( \ . ( , , ,. , \ •' i I , (... i I . , 044
<br />_i
<br />F.-
<br />International Shipments Import to U.S. Export from U.S. Port of entry/exit:
<br />Transporter signature (for exports only): Date leaving U.S.:
<br />CC
<br />ar
<br />Transporter Acknowledgment of Receipt of Materials TRANSPORT! Transporter 1 Printed/Typed Name .. Month Day Year , •
<br />' V i 1 .- i - I 4Lit-I-i.d.4-, i I 09; loci Ili".ir
<br />Transporter 2 Printed/Typed Name Signature Month Day Year
<br />I I I I
<br />Discrepancy .1
<br />Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection
<br />Manifest Reference Number:
<br />-L'i
<br />5 a u_
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: I
<br />a
<br />I-- < z
<br />18c. Signature of Alternate Facility (or Generator) Month Day Year
<br />I I
<br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1 i I
<br />20. designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item 1Ba
<br />Printed/Typed Name Signature,_. Month Day Year
<br />______-.0..-
<br />• A k• 1'1 I .---1 I .
<br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. TRANSPORTER COPY
|