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- r (3 23 ?pip _.... <br /> Please pMt or type.(Form designed for use on.e tWa( tch) r.) Form Approved.OMB NO-2050-0039 <br /> 1.Ger>erator ID Number. 2.Page 1 d S.FJne)pe Mani W Tracking Number <br /> UNIFORM HAZARDOUS b. ' 7-7 JJK <br /> WASTE MANIFEST <br /> 5:Gone" a� &M INC Gerieratoes&IeAddrcss(d aigoo t then malhmg address) <br /> .3400 AUTO PLAZik WAY' n, <br /> ' --Generora Phone: ... r <br /> �-_._:. ._ ._.s;ice,•: =,•: ,:�: .e........••:- - -U.S:EP/►:A-ii�ly�.�-��fl;�� <br /> Vll�.-��111. /14.a ..•' ..:. -.a., ^-^^I -vn ,:•:•J •?•�.' .... ry! --i% it t: <br /> T.Transporter 2 Company Name : U.S.EPA.- Number <br /> 8.Desi'0t z a fA3%1Mr-wr1 U.S.EPA ID Number <br /> M75 SOUTH SOYLE AVENUE T. <br /> W$AWELES GA 90059 C••A 0 0.4 7 O.3 0 9 9 3 <br /> r-arxtya Phone- _ . <br /> 'ga 96.U.S.DOT DrscripYanfln9PmPerrW +nH.Idw+Cie._.:_::_ ;. :10.Co�ttatoYrs.. : .:.; 14:Tdah^? ;12 Uric :: ;:; Waste <br /> FSA end Paotm>g (� ) No.' Typeamey WtJVd. <br /> _.:�: <br /> 12 <br /> Lr <br /> z 2- <br /> 3.3. <br /> 4. !a. • <br /> 14.Spacial Nardng Insbodlate and Addr6onal krfor radon <br /> EM4�GEtlCY P,AFtfAt;T.CliEMTREC 18QO 4�4 93a7t3 NAERG 982:V1*A FOP3CE 9Fi1:AP1916251OILY PAPE., F1LT�RS n' <br /> *'P50400M9312*APPROPMTE PERSONAL PROTECTN E EQUIPMENT <br /> 15. GEIERATOR'SIOFFEROKS CERTffTCATION:I hereby declare that the contents of Otis consignment are fully and accura4i "oy described ay bre proper sh0*9 namie and are bUisilled,pecluged,: <br /> me;Med and lebeledlpWcuded,end are in all respects In proper conation for transport according to applicable Intamartlonal and natlonel govenvr,enlai regcJa6au.If export shipment and I am the Pr*rwy <br /> Fonar•I certify.that"canards of this consig mwd conform to the terms of the atladred EPA Adanrriedgmrnd of Ccrs°ent• <br /> I catffy ti at tiie waste mintmhation statement IderM In 40 CFR 26227(a)[rf,l ami a larva quardMy gereraFor)or @) am a small quantity gener ar)a true <br /> ypad Name l# Sgnatne <br /> Month .Day Year <br /> J 15.Intema(onal 8Ones lg f j �� <br /> r 1 ❑Impart to U.S. ❑eq tt.u.& Port of entry <br /> Z Traapahr aig tune(for a>wb ontA: Dante leaving�J S.: <br /> . <br /> 17.Traisporkr Adcrowkdgrrient of Receipt of Agtsrials �! -`� s' Month Day Year <br /> � T�P 1 yped/5lar, ',x � ` J R <br /> aI <br /> Lo <br /> Trar eporter 2 PdnrodlTyped Name Signature Month Day Yaar <br /> 18.Discrepancy <br /> 18a.Dis gwry wlwdon Space ❑ Owntlly ❑Type ❑Residre ElPartial Reed- ❑Ful Rejection <br /> Man fest Reference Number. <br /> - 18b•Altemate Facky,(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> FacWs Phone: <br /> Mordh DaY Year <br /> Z9 18e, aa m SignalofAl— Faddy(or Generator) <br /> a ; <br /> z <br /> N19.Hazardous Waste Repart Menagament MethW Codes.(I.e„codes for hazardoua Waste treahrc,a;6spoeal,and recyding <br /> LU <br /> Sys") <br /> 1 Z <br /> er 3 4. <br /> v • <br /> 20rigiNsrrw <br /> Designated Faaaty Omor Operaw..CwdfI cation otrec$rof hazardous marLedais co ered by the mtarrlleat except as noted in Item 180 /J r <br /> e ` v signeWre / DDay— Xear <br /> l- �✓\ , J <br /> EPA Form 8700-22(Rev.3-05) Previous edi6ons.are obsolete. . .TRAKISPORTER'S COPY <br />