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,_ . , .. I <br /> kI <br /> please prtnt or type. -I s1w <br /> form AvdONo, 2050.0039 <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2, page 1r3- Eme:rq6n0YrROsponsoP!honoDM!tf:7WASTE MANIFEST neratoes NameandMailiJJK <br /> ng Addtass neralors Silo Address (It different than mailing address) <br /> k <br /> Generators Phone; F <br /> JL <br /> 6 Transporter 1 Company Name Is i U.S. EPA Ib Number <br /> IIIIF <br /> 7. Transporter 2 Company Name I U,S. EPA ID Num er <br /> N <br /> kmr e <br /> 81 iggatedFacikNameandSiteAddress "�y " ` e e-. u ' "" IF <br /> tI <br /> r ; Ck ,F IF FF " - i; Urs, EPA ID Number <br /> t ' c _ <br /> • i <br /> fadiftys hone <br /> _ i I <br /> gas 9b, US. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers <br /> HM and Packing Group (many)) 11, Total 12 Unit 134 Waste Codes <br /> 1, •wow . tIF 0 , No, Type Quantity WtNol, <br /> REr� s ' <br /> 2. IF �, <br /> IF <br /> IF <br /> i <br /> 4: <br /> i <br /> 14 's apd�ing I nshuchonsandAdditionalInformation <br /> - <br /> :. - .. ` - <br /> wL <br /> IF <br /> tsIF <br /> I <br /> 16. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby decfare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classilled, packaged, <br /> marked and labeled/placarded, and are In all respects In proper candttion for transport amrdng to applicable temetionaland national governmental regulations. if export shipment and I em the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAdmowied orpt of Consent - <br /> I certify that the waste minimization statement identified in 40 CFR 2fi2.27(a) (•d l am a large quantity generator or (b) eft,em a small quantity generator)is true, <br /> 6errerala »/QOetot a Printed/Typed Name +y ' S S �at�r + s L } n Day Year <br /> hB x 9 4 r e <br /> IF <br /> 16. Interrrationel3 Ipments v IF „u� ' , _,_tx <br /> ; } <br /> w ❑ Import to U.S, Export from U.so _ Port of ehtrylexil: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> 17, TransponerAdawwledgment of Receipt of Mate dais <br /> Transporter 1 PdnteUlyped Name Signature ; <br /> Month Day Year <br /> oQIF <br /> . : : r : i <br /> FFr <br /> N Transporter 2 Pdntedllyped Name F signature Month Day Year~ <br /> 18. Discrepancy <br /> 18a, Dlscrepancy1ndica0on Space Quantity ❑TyPa ❑ Residue partial ReJed(on ❑ Full Rejection <br /> anifest Reference Number, <br /> 18b• Alternate Faditly (or Generator) U,S, EPA ID Number <br /> U i <br /> LL; Eadiily'e Phone: i <br /> 0 180. S gnature of Alternate Facility (or Generator) Month Day Year <br /> 4 <br /> 19. Hazardous Waste Reporl Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 16 vv 2' 34 <br /> I 4. <br /> . . . . <br /> 20, Designated Facility Owner ar Operator; Certiticallon of receipt of hazardous materials covered byihe manifest ex , pt as noted In Item 18a <br /> Printed/ typed Nems <br /> n 81gn <br /> Cx � w1Q (f "� .� ��✓s :.j *.,�.;' , . ,� .. '4 ... - .f'..x.u. r _x::- [ BE <br /> *t are Month .�Due'.y r <br /> EPA Form 8700.22 (Rev. Va-17)IFF13ravlous editions are obsolete. <br /> DESIGNATED FAGILLTY TO OW .. <br /> i <br />