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W7 <br /> Please print orl F2Sfr designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2051[ta39 <br /> UNIFORM HA7ARIDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency ResponsPhon/ 4.Manifest Tracking Number <br /> WASTE MANIFEST L 00030185jGBF <br /> 5.Generators Nam and Mailing Address Generator's Silo Address(if different than mailing address) <br /> r <br /> i Lrq-4e vx�WV A <br /> Generator's Phone- <br /> 6.Transporter I Company Name U.S.EPA 10 Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> L <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ivm, f. i 2 <br /> Facifty's Phone: <br /> 9a. 9b.U.S.DOT OescrIption(including Proper Shipping Name,Hazard Class,10 Number, 1G.Containers 11.Total 12.Unit 13 Waste Codes <br /> HM and Packing Group(it any)) No. Type Quantity WI.Nol. <br /> I f '. it <br /> 0 <br /> 2 <br /> 4 <br /> 11,.SSpeci <br /> 4 . <br /> Special Handling Instructions and Additional Information <br /> Ail P R16M !:Iitto 01:'1 <br /> 15. GENERATOR*SIOFFEROR'S CERTIFICATION: I hereby declare that the conlerts of this consignment are fully and accurately described above by the proKtshippirg name,at are classilled,packaged, <br /> marked and labelediplacarded,and are in all respects in proper ccirdfthn for transport according lo applicable international and natonal governmental".9416ons.if export shipment and I am me Primary <br /> Exporter,I certify,that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Corsent. <br /> I cortilir that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a iarge quantity generator)or(b)(if I am a small quanfity general is true. <br /> CVefator'sfOffei PrinteclirTyped Name Signature Month Day Year <br /> 113�International Shipments '' <br /> H ❑ <br /> hipmentsLl i..rt to U.S. 7—lExtiortfrom U.S. Portof entry/exit <br /> Transporter signature(for exports only): Cate leaving U.S <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> Ll ansT.1 Printed7yoll ffignaki li�qsA Day Year <br /> 7ra "me <br /> 0 <br /> Z Tfansporter 2 PrinhWTyped Naffie Signature Month Day Year <br /> 18.Discrepancii <br /> 18a.Discrepancy Indication Space ❑ Q.ntily ❑Type El Residue ❑Partial Reocfim ❑Full Rejection <br /> Manifest Reference Number: <br /> 1 Bb Alternate FarAity(or Generator) U.S,EPA ID Number <br /> LL Facility'sPhore: <br /> 18c.Signature ofAlternate Facility(or Generator) Month Day Year <br /> 9 Hazardous Waste Report Management Method Codes codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4 <br /> 20.Designated Facifty Owner of Operator.Certification of receipt of hazardous nialLrials covered by the manifest except as noted in Item 18a <br /> Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />