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Please print or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved.OMB No,20500039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Pagelof 3 Emergency.Response Phone 4M "rt(�t et¢.p91urPe4" „ , <br /> WASTE MANIFEST <br /> eJ J <br /> 5.Generators Name and Mailing Add ess Generators Site Address(if di0erent than mailing address) <br /> Generators Phone. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number, <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and SBeAedress - U.S.EPA ID Number <br /> Fano Phone: <br /> gra 9b.US.DOT Description(mcludarg Pm:er Shipping NaTe l--.,d Class,ID Number, 10.Coreall am 11.Total 12,Unit 13.Waste Codes <br /> HM and Pack"iI Gra:p(0 ahyr, No. Type 6ua'IiN Wt.Nol. <br /> 1. .. <br /> K <br /> 4 <br /> z 2, <br /> 'Jul <br /> t9 <br /> l <br /> 3. <br /> C <br /> i <br /> 14.Spepal.9andling InsLvc4ons and Additional Infprinv,( <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: i hereby declare that the contents of this=signment are fully and accurately ceserlbed above by the propershepping name,and are classified,packaged, <br /> marked and Iabeledlplaarded,and are In all respells m propercondl er,for transport according to applicant intemationaland national govemrrertel reguiaoms.If export shipment and am the Primary <br /> Exporter.I party that the cor enls of this consignment conform to the terns of the attached EPAAckrimledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(ifI are a small quaintly generator)Is true. <br /> GecerabesrOffii PiintedrTyped Name Signai Month Day Year <br /> rr 16. <br /> International Shire mats <br /> i- lJ Import to U.S. IJ Export from U.S. Port of enlrylexit: <br /> Transporter signature(for exports only): Date taviig U.S.: <br /> d' 17.7ramportarAcknowfedgment N Receipt of Materials <br /> Transporter 1 PdntedlTyped Name Signature Month Day Year <br /> O <br /> Q. <br /> N <br /> 2 Transporter2 PrimindlTypedName Signature Month Day Year <br /> F- <br /> } 18.Discrepaincy I- <br /> 18a.Discrepancy Indrabon Space , Type E Resioue ❑Partial Reaction ❑FOR pajed. <br /> Manifest Refererce Number: <br /> 186.Niernwe Facitily(or Generator) U.S.EPA ID Number <br /> U <br /> W Falaiitys Plena: <br /> W 18c.Signature of Alternate Facility for Generator) Monty Day Year <br /> Q <br /> Z <br /> US 19.Hazardous Waste Report Management Method Codes n e.,codes for hazardous wast treatment,disposal,and recyding system,<; <br /> C 1. 2. 3. 4, <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by Bre manifest accept as noted in Item 18a <br /> PdmedTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev 3-05) Previous edRlons are obsolete. GENERATOR'S INITIAL COPY <br />