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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 ID Number 2 Page I of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 00d:J- 3`01G <br /> 786 BF <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generators Phare! <br /> 6.Transporter 1 Comp"Name U.S.EPA ID Number <br /> 7 Transporter 2 Company Name US.EPA ID Number <br /> 5.Designated Facility Name and Site Address J S.EPA 0 Number <br /> ,EW NwAxi Catt'"a Ll-t, <br /> T'lo <br /> Facility's Phone, 11- <br /> 9a 9b.U.S.DOT Description(including Proper$luoprg Name.Hazard Class,11)Number, 10.Containers 11.Total 12.unit 13.Waste Codes <br /> HM and Padkiing Group{if any)) No, Type Quantity Wtivol <br /> 2 <br /> Uj <br /> 3 <br /> 4 <br /> 14 Special Handling instructions and Additionai Information <br /> 11.4 0- 4'! K,-.50 1!i-i) Wtj ri I-F' <br /> 15. GENERATOR'StOFFEROR'S CERTIFICATION: I hereby declare mint the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledfpJacarded,and are in A]respects in proper condition for transport according to applicable international and national governmental regulations.9 export shipment and I am the Primary <br /> Exporter,I certify that the contents of this coirisignmeni conform to the terms of the attached EPAAdnowledgment of Consent. <br /> �l carth that the waste minimization statement identified in 40 CFR 26217(al(it I am a large quanbry generator)or(b)(if I am a small quantity generator)is true. <br /> C*61ralor,,lOfferors PrintedrTyped Name Signatureoj'h D year <br /> 11 " 1 <br /> _J -16.International Shipments <br /> r 11 Import to U.S. aw from U.S. Port ofentrylexit: - <br /> =— Transporter signature(for exports only), Date leaving U.S.: <br /> ix <br /> LU t7 Tramciporler AOmwledgment of Receipt of Matenats <br /> Tia erii PrtnlediTyped a tl SdcOnatu <br /> Mont, Da "A <br /> C.. <br /> rn <br /> 0 <br /> CL <br /> 2 Transporter 2 Pnnledflyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space F j Ouanbty Type Residue Partial Rejection i Full Rejection <br /> Manifest Reference Number <br /> ifib Alternate Facility(or Generator) U.S.EPA 10 Nvmher <br /> ra FacifiVS Phone <br /> LLJ C3 18c.Signature of AAtemate Facility(or Generator) Month Day Year <br /> !W <br /> Z <br /> 019. Report Management Method Codes(i e.,codes for hazardous waste treatment,disix)sai,and recycling systems) <br /> Hazardous Waste <br /> 20.Desginaled Fadily Owner or Operator.CaMration of receipt of hazardous materials cavered by the manifest except as nded in Ilem 18a <br /> PrintedfTyped Name Signature Month Day Year <br /> EPA Fong 8700-22(Rev.3-05) Previous editions are obsolete. <br /> AFNFQ1k'MR1q JNMAI f1r,10V <br />