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Please pbnTor type`. Form-do' nod for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UMFOW-HAZARDOUS 1. aneralar ID Number 2.Page I of 3.Emergency Response Phone . 4.Manifest Tracking Number <br /> � �'x p <br /> WASTE MANIFEST �1.;`.`:a =(.+a a .t-+.i�[!ti�1t6�6r�TM�t '� .� 1 f 0 G B F <br /> 5.Generalor's Name;lW Ma itV Address Generalor's Site Address fd different than mailing address) w <br /> t TTlSAL SOW.%.m+lt. <br /> i Rite WAT <br /> WIIICKT-,'�Illrf,IC-6 9W <br /> Generators Phone- ..:t4' 3•ii r: <br /> 6.Transporter 1 Company Name U.S EPA ID Number <br /> l+ti,t'=cia K-rr.`fCriifTl'#i9:a) ;f `ANI!. JM 1"'f1+},(lA <br /> 7.Transporter 2 Company Name U.S.EPA Ip Number <br /> 8.DeyWa�d" and Sit gess U.S.EPA 10 Number <br /> Facifil es Phone: <br /> ilr+.z)14 iWo <br /> ga 9b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10 Conlainers 11 Total 12.Unit 13 Warta Codes <br /> HM and Packing Group(if any)) No. Type Ouansly Wt_Nol- <br /> x <br /> w <br /> z 2. KMIlTt,RR PG4-3s-'30;1- „ r <br /> LU <br /> c9 0 <br /> 3. <br /> i <br /> 4. <br /> 14.Special Handling Insbuctions and Additional Information <br /> tt� li1t�'R 'i{i <br /> OEQ��40 t'tF:. TFiHIN�' nl>I��iR i PL <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 labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations_11 export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the allached EPAAcknowledgmenl of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> loetiCfferoePrinted/T ped Name I Signature Month p�ary Y <br /> or <br /> 16 Intemalionaf Stspmenls <br /> L.Import to U.S. ❑Export from U,S. Port of entrylexit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> U 17 Transporter Adtnowledgmenl of Receipt of Materials 1 <br /> Trans 1 Rnmetirrypeftiame <br /> S [[._ Monthq 1Day <br /> Yeato <br /> rly <br /> IL <br /> Q Transporter 2 Prmled/Typed Name $ignaerre f JF Month Day Y <br /> t- <br /> 18.Discraparcy <br /> i8a.Discrepancy Indication Space ❑ puantity El Type ❑Residue ❑Partial Rejection <br /> Manifest Refererce Number r . I <br /> 18b.Allemate Facility(or Generator) U.S.EPA ID Num <br /> 1t E <br /> V <br /> U. FacRt tys Phone: <br /> 18c.Signature ofAttemate Facility(or Generator) ,1 ' Day Year <br /> _19.Hazardous Waste Report Management Method Codes(iR.codes for hazardous waste treatment,disposal,and recycling systems) (' <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except VS2etsdItafn 18a' <br /> PrmtedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />