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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 I Generator'D Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> I <br /> 111 <br /> WASTE MANIFEST .0 1. 0003 1 6 5 9 G B F <br /> J 5.Generators Name and Mailing Address Generators Site Address Of different than mailing address) <br /> nerle'let.Jfl% <br /> -t" 1 <br /> Generators es Phone: <br /> 6.Tiansponer 1 ComPWY gaft U.S.EPA ID Number <br /> r.-qj 31 <br /> 7.Transporter 2 Company Name U S.EPA ID Number <br /> 8.Designated FKAly,Name and Site Address JS EPA ID Number <br /> GVA N&WtIO t;Q10'0A LLA. <br /> 165 vuh"(d fkock I&'oA4 <br /> 42 <br /> FacA P's Phone:VI --470 <br /> go. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any <br /> No Type Quantity Wt./Vol. <br /> 0 <br /> Z 2. <br /> LU <br /> 3. <br /> 4, <br /> .14 Speciai Handfrq Instructions and Additional Information <br /> 111-3 OF :±:_ <br /> 15, GENERATOR'SfOFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged. <br /> marked and labeled1placanded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations If export shipment and I am the Pqmary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmem of Consent. <br /> I I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(I I am a sMil quantity generator)is hue <br /> Ggheralpa's/Offeroes PrintediTypea Name Signature Month Day year <br /> I I� t-) <br /> =J' 16.lnternational Shipments <br /> l'- El Import to J.S. E Export from U.S Port of entrylexil: <br /> Tz Transporter signature(for exports only): Date teaving U.S.: <br /> IX 17.Transporter Acknewtedgment of Receipt of Materials <br /> LLI <br /> 6i Transpor4fr I PrintediTyped t"RF Sig4hrel Month Day Year <br /> 0 <br /> ZTransporter 2?rIntedfTyped Name Signature Month Day Year' <br /> oc <br /> 18 Discrepancy <br /> 18a.Dscreparcy Indication Space E 0..ntty L1 Type D Residue ElPartial Rejection I Full Rejection <br /> Manifest Reference Number <br /> 18b Alternate Facility{cr Generator) U.S.EPA ID Number <br /> Faciliys Phone: <br /> LO-1-8c Signature of Aftemale Facility(or Generator) Month Day Year <br /> 49.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 2. 11 -7 <br /> 20,Designated Faciftly Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />