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Please orint or Form desi ned for use on elite (12-pitch)tveewriter <br /> Form Approved. OMB No. 2050-0039 4 GENERATOR ).- . ,. . <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator er Pac, 1 of 3. Eier e cy espon a <br />0 <br />. Manifest Tracking Number <br />0 0 3 5 3 7 4 18 G B F <br />GeneratMdttyl <br />Generators Phone: <br />Irg Add yr/clic/ . 60 c__c ,Generators siteexAkaresslif different pan maiiing address) O _ <br />ce-tvcc Co4 A0•... <br />al P/tir5 JO\ <br />to0/ att 1 MoS\te_to,-,01k 'ViolP <br />U.S. TranspAriCtrnpany Naremi-iii,Ajmt,4* ii z/u/ tliquID teoor s <br />*-5 z(z, a7?J/10- <br />0 <br />Transporter 2 o an Name U.S. EPA ID Number <br />ek lit 4/tivAtArW SO &/ 770I-5 Ph ril 2-,5-22_ ..,„, <br />Designated Facility Name and Site Address A 0 S7EPA ID Number <br />1 pm-5w 571,77°A. u• <br />VI OA) inVA-74(.., -'• & X) <br />31J.5- 14)10 <br />4 <br />0/ <br />Facility's Phone: (41 X:04. -`Vifill I <br />r- - /4z z-goa)5-2-0c77r-- <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 WI.Nol. <br />1. kick) W-4 ilbilitth <br />9oLl 19 (476,4661)--i- <br />igt/Jf kik to <br />. <br /> <br /> <br />Special Handling Instructigns <br />I) elkS ILI 949" <br />and Additional Information <br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, aid 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 lam 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 quanti tor) is true. <br />Generators/Oero Printed/Ty.- r Nanle Signature Month Day Year <br />15 1 I. 1 2:4 <br />r- <br />-, <br />_.16. International Shipments Import to U.S. Export from U.S/ Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: TR ANSPORTER 17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Pr. te. ped me <br />' <br />Signature Month Day Year <br />K/ 5,/,tql I C; I rl- I 22- <br />Trans - Pnnted/Typed Name Signature Month Day Year <br />c; 1 I'l 122- I .4-- DESIGNATED FACILITY ------) 1. 18. Discrepancy -- <br />Discrepancy Indication Space Elill Quantity LII Type LIII Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />Signature of Alternate Facility (or Generator) Month Day Year <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1 <br />Lki \ <br />2. 3 4. <br />20. Designated Facility Owner or Operator: Certitica ion of receipt of hazardous materials covered by the manifest except as ncted in Item 18a <br />Printed/Typed Namejoar () Signature <br />- rf\'1) 1 r\p's 1 C4 Month Day Year v I 51 3 1 la74 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />DESIG ATED FACILITY TO DESTINATION STATE (IF REQUIRED)