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Please print or type.(Farre designed for use on elite(12-pitch)typewriter.) Form Approved.OMR No.2050-0039
<br /> UNIFORM HAZARDOUS 1-.Generator ID Number 2.Page 1 of 3.Emergency Response Phone J4,Manifest Tracklrt Numbar /'.
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<br /> WASTE MANWEST e.t�1..F;y# t�a� `t{">_1. I.; a*t= r .;17.-1f:�T�01 2V 3407 D}`''�T
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<br /> 5.Genesatofs Name andSS22Mailing Address Generatoris Site Addmss(if di€ferentihan mailing address)
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<br /> GeneralofsPtuna: `rtir.>! 51 S:Zi ro§.?#: r L <....r=�:
<br /> S.TrarFspx'ter i Qzpany Name U.S.EPA ID Number
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<br /> 7.Transporier 2 Company Name U.S.EPA ID Number
<br /> 8.Designated Facility Naas and Site Address- U.S.EPA ID Number.
<br /> Faclity's Pt;or,8:ie,'I h-
<br /> Aa. Eb.U.S,007 Description(including Proper Shipping Name,Hazard Cs ass,ID Number, 10.Containers 11.Total 12.Unit 13.`fileste,Codes
<br /> HM and PactingGroup(if any)) - No. Type .Quantity Wt.Nol.
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<br /> 14.Special Handling Ipstrnct ons and Additional.Information
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<br /> 15. GENERATOR`S(OFFEROR'S CERTIFICATION: I hereby declare that the cantenis of this consignment are fully and accurately described absre by the proper shipping name,and are classified,packaged,
<br /> marked and iabeiadfplacarded,and are in all respects in proper cond-Kon fastranspori according to applicable international and naliwtal goyemmantal regulations.If export shipment and I=the Primary
<br /> Exporter,l oeltify that rte contents of this consignment conform to the terms of the attached EPAAcknowledgment of Concent.
<br /> Ice*that the waste minimization statement iden0ed in 40 CFR 262.27(a)(if i am a large quantity generator)or(b)(if)am a small qQ" ntily generator)is true.
<br /> Geoeraloes,f0fte's PrintedfTyped Name Signature klonO) Darr Year
<br /> -I 16.International shipment$
<br /> ❑Import to US. ❑Export from U.S. Po:#of entrylexit:
<br /> z Transporter signature(for exports only): Date leaving U,&
<br /> w 1;'.Transporterkknowled3menfofReceipt ofMaterials
<br /> Traps rter7 Priatedfl'ypedNante '. 1/{f Signature Month tea) Yea;
<br /> a Transporter2 PrintedFi-yped Name Signature ;..:i lonFh Day ..year
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<br /> 18.Disrsep2ncy
<br /> 18a,Discrepancy IndEcakon Space ❑ Quantitytype ssE-1 Full Re
<br /> ❑ yp ❑Ridus Partial Rejection #ecticn
<br /> Mardlest Reier4mce Number,
<br /> 18b.Akemate Fa6ity(or:Generator) - U.S.EPA ID Number
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<br /> FQi Facility's F tore:
<br /> LU 18c.'SlgnatursoFA3emateFacility(or Generator) i'rlonth Day Year
<br /> 1S HazerdQus Waste Report Management Method Codes(i.e.,codes for hazardofss waste treatment,disposal,and recycling systems)
<br /> 2. 3. 4
<br /> co.Designated Faal ty Dww o.Operator:Certification of receipt of hazardous materials cove ed by the manifest except as ruled in Item 18a
<br /> Pnrdedffyped Name Signature Month- Day_ Year
<br /> EPA Form 8740-22(Rev.3-45) Previous editions are obsolete. GENERATOR'S INITIAL COPY
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