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Please print or type,(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1,Generator ID Number 2 Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> S <br /> WASTE MANIFEST --1 761e) KS <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> "D V QC" rl, r.a 1'. it 9 ci'r 1?.t.cz- Ir'.' <br /> r@210 E <br /> 'Q 74 f I <br /> Generators Phone: <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> T X R 0 OCIZ 120�5, <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site AddressU.S,EPA 10 Number <br /> 1xi 75276 <br /> Facility's Phone: lt,2 6"2.t'NO <br /> 9a. 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 /> WMA.- 'NIDI'l s{ tit HMARRMNH) W"A'STE Sol-JIDS"�k <br /> U I <br /> Z 2. <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> TE 1)U F;f— 702'064'e H,E.19 7 7 0 t""•is <br /> P-111. HIR E:V11:7 (SK l yi�I <br /> 11111,111-1 P18 f3y GEN "I'D VZiMWIN Lff".IIENSED �All) AS N0-X#,T:',A'RV <br /> "'i :1 11-14 fl. <br /> 1 CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are clasisified,packaged, <br /> marked and labeledliplacarded,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 I am a large quantity,generator)or(b)(if I am a small quantity generator)is true, <br /> Generator'slOffaror's Prinlecirryped Name Sign'atufe Month Day Year <br /> —1 16.Intemational Shipments <br /> P- 0 Import I.U.S. El Export from U.S, Port of entry/exit—I" <br /> 9 Transporter signature(for exports only): Date leaving U.S.: <br /> LU <br /> L% 17.TranspolerAcknowledgment of Receipt of Materials <br /> Trpfi$porfer I PrInte Mped NaTe Signature- Month Day Year <br /> 0 <br /> CL <br /> In <br /> Transporter 2 Pdntedrryped Name !�-.-Sljnature Month Day Year <br /> 18,Discrepancy <br /> 118a.Discrepancy Indication Space 0 Quantity El Type El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL Facility's Phone: <br /> LC3 18c.Signature of Alternate Month Day Year <br /> mate Facility(or Generator) <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4 <br /> 2. . <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATORS INITIAL COPY <br />