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e-( <br /> Please print or type..(Fom1 designed for use on elite(12• itch) niter.) t ( ` 1 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Genmlor ID Number 2.Page S of 3.Emergency Response Phone 4.Manifest Tracking Number (((c <br /> WASTE MANIFEST ttvt•.:1 ; tithN •ac c1 - — r ' V I�a7 <br /> .t <br /> 5 Generatoes Name and Matting Address Generator's Site Address(d different than mailing address) <br /> .1 F( 1 CI'Fi <br /> Generator's Phone: <br /> 5 Transporter 1 Company Name U.S.EPA ID Number <br /> . . . ;rt4'1+V71GE1:r1l1 i.3td <br /> 7 Transporter 2 Company Name U S.EPA ID Number <br /> d.Designated Facility Name and Site Address .r t U,$.ETP umber - <br /> 1 <br /> i'. '1:1' :'. .. <br /> 'I -,A 'iC!A 7'1,71 <br /> Facile ys Phone' <br /> 9a 9b U S DOT Oescription(Inchiding Proper Shipping Name.Hazard Class,ID Number. ' 10 Containers 11 rola Q.Unit <br /> HM t <br /> and Packing Group(it any)) NO Type Quantity Wt t 3.Waste Codes <br /> ,Y 1. NI)N ,1 ,,:, :i lilt,. "' 0141S 1 <br /> ri <br /> z 2 <br /> w <br /> I4.Speaal Handling Instructions and Additional Information <br /> ,:'4 Hli t 1`1 R6t•µt.Y NF1—±mil wE,fl 1 1t;,P t-`.RF-f rY •I(l t '*u t.,i,:N l pito; i 4`;4 JI <br /> 15. GENERATOR'SIOFFE 0 '3 C C TION;r y d are that contents �h s cons muni are aced licca &. y Fie proper shippu g name,and are class fled,packaged, <br /> marked and Iabeledlplacarded,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 ce"that the contents of this oonsgnment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I car*that the waste minimization statement Identified in 40 CFR 282.27(a)(if 1 am a large quantlry generator)or(b)(if I am a small quaalikgeneratorj is one. <br /> Generator PrfntedlTyped N Signature Month Day Year <br /> T T st, <br /> f <br /> 16 Intemational Shpimanis <br /> Impon to U.S. ❑Expert from U. P of entrylexit __-_--.-- <br /> Z Transporter signature(for exports only): Date leaving U.S.- <br /> W 17.Transporter Adv wAedgment of Receipt of Materials <br /> oc Transporter 1 Printedfryped Name Signature Month Day Year <br /> CL j - <br /> rn <br /> 2 Trans 2 Priritedffyped Name Signature Month bay Year <br /> Q <br /> PC <br /> f.. <br /> 18.Discrepancy n�T f� <br /> 18a Discrepancy Indication Space Quantity ❑Type LJ Residue ElPartialRe)ecbw Dull Full Re•acuon <br /> Manifest Reference Number. <br /> 18b,Allemale Facility(or Generator) U.S EPA ID Number <br /> U <br /> uQ. Facility's Phone. <br /> 18c,Signature o(Altemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i a.cedes for hazardous waste treatment,disposal•and recycling systems) <br /> UJ G 1. 3 4 <br /> 20.Des grated Faality Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnted7Typed NameSignature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />