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Please print or type.(Form designed for use on elite(12-pitchlipewriter.) <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS trlP Nypspar, 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 4. -shO-0J�'.-P87 j 112157 B F <br /> 5.Generators Name and Mallin Address Generators Site Address fif different than mailing address) <br /> P1C;I'4-"1UL1. • <br /> Generators Phone: 1 .�}} > o,211 <br /> 6.Transporter 1 Company Name U <br /> AJfRftA%1r291V 51 <br /> 7.Transporter 2 Company Name U.S.EPA IQ Number <br /> 8.Designated Facility Name and Site Address US.EPA ID Number <br /> i':FtI hteGyrnlilrm selvit;e Irwe WIR000029�''a'A'M�i <br /> 101 Gt <br /> Facii s h(0Jr?4F- 1 11 54(08 91I10,241..;d# 04 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity Wt,Nol. <br /> 1. <br /> '03 <br /> F-0 Nora-RCRA HRZ;I d0t1S WaSte Re>!d ra _ <br /> z 2. <br /> w i <br /> c� <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> V*41 Pnaltol�� Glothfng and L-ytrweis 91 OILY Ai:'S(1t?Bf7Nt F: �c'_(3 !� ! X171 <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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intemationai and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 2 2.27(a)(if I am a large quantity generator)or(b)(if I am a s all quantity generator)is true. <br /> GeheratoeslOfferoes Printed/Typed Name Signature Month Day Year <br /> i <br /> i <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S, Poileavin <br /> t _ <br /> Transporter signature(for exports only): <br /> Da .: <br /> w 17.Transporter Acknowledgment of Receipt of Malerals <br /> Transporter 1 Printedfryped Name Signature Month Day Year <br /> QTransporter 2 Printed/Typed Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Attemate Facility{Cr Generator) U.S.EPA ID Number <br /> 'J <br /> v <br /> w Facility's Phone: <br /> WJ 18c Signature ofAltemate Facility for Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LAJ In 1 2. 3. 4. <br /> [2:0-Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />