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Ple7lpTTRTPdr'jite,(Form designed for use on elite(12-pitch)typewriter.) Form Approved-©MB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> 6J8 6 GBF <br /> NlASTEMANIFE5T a:i:�i;'''. t _��f.4d:t+4-'-X3tr?-s:ti�kriiFr6?i, r <br /> 5.Generator's Name and fli406AddreR_ Generalor's SiteAddms(it different than mailing address) <br /> 1l�fh�sry:4i <br /> Generator's Phone: j s_t u <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> -'tAtj*FrINIMMTt+ OM 'I"01101jet, fes' CIttilffR x ?.a+,{i C.'"pf t01IEt I <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.DeWQdfi(1r Nae and Site Address U.S.EPA ID Number <br /> 141 Twemim <br /> n'i,ninth <br /> Facility's Phone: <br /> 9, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11-Total 12.Unit <br /> 13.Waste Godes <br /> HM and Packing Group(if any)) <br /> No. Type Ouumfity WtNd. <br /> 1 ,•wR Mk'1 - . Aa.drr tW9 .; --k", f..r rt". <br /> �O <br /> w <br /> Z 2 <br /> w <br /> C7 -- <br /> 3, <br /> f <br /> 4. ' <br /> 14-Spew Handling Instructions and Additional Information <br /> to t,4 !0 in il3nra- :111d-air -- <br /> ';9+f1 <br /> 15. GENERATOR'SIOFFEROR'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,packaged. <br /> marked and labeiedJplacarrled,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,l certify that the contents of this consignment conform to the lerms of the attached EPAAckroMedgment of Consent <br /> I certify Tol the waste minimrzation Statement identified in 40 CFR 262.27{a)(if I am a large quantity generator)or(b)(01 am a small quantity generator)is true. <br /> Generabesf0fferor's PrmtedlTyped Name f Signature Month Day Year <br /> �j 16 International Shipments <br /> F— 11 Import to U.S. ❑Ezpon from U.S. Port of enlrylexl: <br /> Transporter signature;for exports only): Date leaving U.S.: <br /> Li 17 Transporter AckrmvWedgnenlof Recmipt of Malmia6 <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> 2 Transporter 2 Prinledifyped Nakte Signature Month Day Year <br /> LY <br /> 18.Disc epancy <br /> 18a.Discrepancy Indication SpaceOuarlily t—TypeLJ Residua Partial Reject on 0 Full React ort <br /> C <br /> Manifest Reference Number. <br /> 18b.ANemate Facility to Generator) U S-FPA ID Number <br /> V <br /> Facility's Phare: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2 3. 4- <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as anted in Item 18a <br /> PrntedffypedName Slignature Month Day Year <br /> EPA Form 8700-22(Rev 3-05) Previous editions are obsolete. <br /> GENERATOR'S INMAL COPY <br />