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Please print or type.(Form clesjgnied for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> [UNIFORM HAZARDOUS 1 1 Generator ID Number 2 Page 1 of�3Emergercy Response Phone 4.Manifest Tracking Numtwr <br /> 30 WASTE MANIFEST K .90- 0605GBF <br /> 5.Generator's Name and M30'rig Address Generator's Site Address(if different than mailing address) <br /> '41it <br /> Generator'sPhow �:'j A-, <br /> 6.Transporter I Company Name U.S EPA ID Number <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8. W Rj~+Ldress U.S.EPAID Number <br /> Facility's Phone: <br /> 9, gb.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 Not. <br /> 771 <br /> 0 ------ <br /> Z 2. <br /> UJ <br /> 3 <br /> 4, <br /> 14 Special Handling Instructions and Additional Information <br /> Oat JfAtlf'r '10 Ett -iij 17 40jeg)-i•1 iVVE—F PPF <br /> 15 GENERATOR'SIOFFEROR'SCERTIFiCATION: I hereby declare Mal the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,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 In the terms of the attached EPAAcknowledgmkpipf Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quant y generator)or(b)(if tam a small quantity generator)is Ince, <br /> Gawatoes*fferoes PrintedlTyped Name Signature Month Day Year <br /> .j 16 11afinnalShipments Import to U.S. Export from U.S. Port of entrylexil: <br /> Transporter signature(for exports onty): Dae leaving U.S.: <br /> LX 17.TransporterAcknowledgmeni of Receipt of Materials <br /> L1 <br /> Transporter 1 PYrinlecl[T d Signature Month Day Year <br /> 0 <br /> CL <br /> Cn <br /> Transporter 2 PrintediTypied Name '%loom- Month Day Year <br /> OQG <br /> 18.Discrepancy <br /> laa.Discrepancy Indication Space Quantity ❑Type EIResidue Ej Parkai RejectionE]Fuil Reflection <br /> Manifest Reference Number: <br /> 18b.AfternateFadily(or Gen�tor) U.S EPA V Number <br /> tai FwAty's Phone <br /> Ljj 1 Be.Signature of Alternate Facility( Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 7 1 2. T. 4. <br /> 20 Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as riled in Item 18a <br /> Pnntedffyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev 3-05) Previous editions are obsolete <br /> GENERATOR'S INITIAL COPY <br />