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Please print or type. Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gendhior'10 Nbmber 2.Page 1 of 3.Emergency Response Phone 4.Man Ifest Trackop Aumbu <br /> - f 117 <br /> WASTE 7ANIFEST 0 7 6 FLE <br /> 5. Narre a..d Mailing Address Generators Site Address(if different than mailing address) <br /> M p)F�t C; <br /> 1()'-(7'7 1 <br /> 6.Tr3 nsp D"er 1 C D.7p Ei.-.y N aTo U.S,EPA 11)Number <br /> Ad'v-,i-icad Cheaiical Tfvnqp_-,-L [tic G A R200 171017 <br /> 7.Transporter 2 Company Name US.EPA ID Number <br /> Ren-,od'al Thamportation SeMcclz- <br /> 8, Fncilay Karre ad Site Ada-ess U.S.EPA ID Number <br /> 1, -;,-0 T -130 Zec 7 <br /> JLl. <br /> Facility's shone; sf'.?_34cll 5Mj <br /> 9a, 91b,U.S,DOT Description(including Proper Shipping Name,Hazard Cass,ID Number, 10.Corntalners 11,Total 12.Unit 13.Waste Codes <br /> HM and Pacildrig Group(if any)) No. Type Quantity Wt_rw' <br /> w PC RA Hayafd a us V%Ias tLa L I qui L11(Vater) <br /> 0 <br /> Z 21JN2u09,Waste Mercury,8 (6.1),PGM 725 0009 <br /> if DF <br /> 3. <br /> +1 <br /> 4. — ------------------ <br /> 14,Spedial Handling Instructions and Additional Information Flrr�j%at Numbur 4-152'93 Docuwmt it. D503615 <br /> 1) OTO <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION-I herabydectare thal the contents ufLli;s consignment are'Jlya-d 9....::ratpfly described above by the proper shipping name,and are classified,packaged, <br /> marked and ia;p,r2ok;lacarded,and are in all respects in proper condition for'ja�s por:according to app:ica app: k';ri tc rriai:xial and national governmental regulations.If shipment and I am the Primary <br /> Exporter,I certify th a:the�'.on te:ts of this,D:i s ic n r-i P-!cD-orm to the ta—ns of t�e qtta z�hed EPA Acknowled-.w n t of Dons T. <br /> certify illy ger�loir 1S.In <br /> I rtify thatVe ivas%mriffi <br /> in miza.on statement ideed in 40 CFR 26127(a)(if I am a large quantity gener nr)0.r(bjf1'9Aawa�<L14 <br /> PriaLow'T <br /> ypedL�t �« �' �1 5 Name Wnth -Day J.�g <br /> t <br /> _j 16.1riwationalShipmerits _0 <br /> Import t U.S. El Export from U.S. Port of entrylexii: <br /> •TranspotLr 5'griL&xe(for exeMq only): - Date leaving U.S.: <br /> CCLU 17.TransponsrA-,�.-.owWedgment o;Receipt of Materials <br /> Transporter 1 Pirriledrryped NE1710 Signature Month Day Y, <br /> Transpoper 2 Printedr-yped Name 7ff bignatute Month Day Year/ <br /> 18.Dstrepancy <br /> 18a.Discrepancy indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Genei-aloo U.S.EPA ID Number <br /> Facility's Phone: <br /> juj 18c,Signatureof Alternate Facility(or Generator) lknih Day Year <br /> Z <br /> !2 79._Ha Irdqk Waste R.ArtArp—agerneN Method Codes yl <br /> 96des for hazardous Osle treatment,disposal,and recycling systems) <br /> 4, <br /> LLI <br /> 20. receip-..of hazardo.s maleriaYcovered by the ma-:ifj61jX�0)p1 as nZtqd inIrtern 18a 77 <br /> diTyp fte�- -5j kbre Month Day c Year <br /> EPA Form 8700-22(Rev.12-17�-Previous edifo ns are o bs o l0e. LDES�IGNATED FACIMYTO GENERATOR <br />