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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 10 liumber 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST �Iyj�],"j rjA�'k." 1 000301057 GBF <br /> 5 Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generators Phone: <br /> B.Transporter I Company—,Name, U.S.EPA ID Number <br /> Isw 1-1w1w. A'51)3�SKJ- ,W' <br /> 7.Transporter 2 Company Name U S.FPA 10 Number <br /> Dots- aled Facility Name and Site Address U.S EPA ID Number <br /> 13 I <br /> .,r- All)�I.4tJoM 1,L4 . "!!'�I <br /> I i-;eZ W"Ili? Road <br /> Fadtys Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11 Total 12 Unit 13.Waste Codes <br /> HM and Packing Group(if any)} No. Type Quanfily vvt.?VOI, <br /> 1. 4.0ijis Kt-W 4 tj 1.A 60+4'.' <br /> Ix <br /> 0 <br /> Z 2 <br /> LLI <br /> 0 <br /> 3 <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> ;15 GENERATOR'SIDFFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are Classified.packagee, <br /> marked and labeledliplacarded,and are in 4 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 cerldy that the contents of this consignment conform to the tennis,of the attached El"AAckrowledgmerd of Consent. <br /> 12 tit'IM the waste minimization statement iderillfied in 40 CFR 262,27(a)(if I am a large quaintly generator)or{h)(if I am a small quantity generator)is true. <br /> atoesJOffercWs Printed(Typed Name Signature Month Day Year <br /> r <br /> i 16.In aboral Shipments <br /> Lj Import 10 U.S- ❑Export from U.S Port of eri <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> Lu <br /> 17.Transporter Acknowledgment of Receipt of Malenals <br /> 0 4— <br /> Q! 7'11i�rl Pn tedrryped Nanie. Si Month I 93yj <br /> ZKL porter 2 PrintedlTyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space L Quantity ❑Type 1-1 Residue E Partial Relection ❑Full Riijectlon <br /> Manifest Reference Number: <br /> 18b AAermle Facility(or Generator) U.S.EPA ID Number <br /> Iii Facililys Phone: <br /> Lu 18c.Signature of Alternate Faulty(or Generator) Month Day Year <br /> !R <br /> Z <br /> 19 Hazardous Waste Report Management Method Codes(i.e„codas for hazardous waste treatment,disposal,and recycling systems) <br /> 2. <br /> 20.Designated Faintly Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as ricled in Item 18a <br /> .m�0 <br /> rinse ypZed Name Signature Month Day Year <br /> EPA Form 8100-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INMAL COPY <br />