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Please print or type.[Faruk designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1 r���rO Form Approved.OMB No.2050 o039 <br /> 2 Page 1 of 3 m r en a jne 4.Manifest Tracking Number [] <br /> WASTE MANIFEST �� ��L ��(� �, ��3 v..1 � G B F <br /> d�Mailin Addr <br /> Generators Site Address of different than mailing address) <br /> 3 C � � _ <br /> 3ernralc s Phon b <br /> 6 CRI'R&Offifiib Service in J v ["MR00002 61 <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> '� <br /> rs , <br /> `• , C*� <br /> Faciiity's Phone: 1 t � <br /> 9b.U.S.DOT Description(includingprpping Proper Shipping Name,Hazard Class,ID Number, <br /> 9a '0- <br /> HM and PaG[thg Group(if anrl) Containers 1�.Total 12.Unit <br /> 1 No. Type Ouant�'ry, Wt t3.'NasleCndes <br /> o Non-R RA Hazardous Waste Solid 3 <br /> Z 2, �, <br /> ,L <br /> `FyeWear. 5.1 -OILY ABSORBENT <br /> E.R.G.-5.1 ##17.1 <br /> C-P-01"�'e -t§-- u2c)L4 0(2 a 09,V-ST <br /> 15. GENE RATOR'SlOFFEROR'S CERTIFICATION: I hereby declare Thal the contents of this consignment are fully and accurately describedabove by the proper;hipping name,_na packaged, <br /> marked and lobeledlplacarded,and are in aH respects in proper condition for transport according to applicable international and national governmental regulations.if expo d shipment and i am the Primary <br /> Exporter,I certify,that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> f certify that the waste minimization statement identified in 46 CFR 262,27(a)(if 1 am a Targe quantity generator)or(b)(if 1 am a small quantity generator)is true. <br /> Generaloesl0fferoes Printedrfyped Name Sign <br /> honlh Day Year <br /> 1 16-n n oralipmen[s AX y 31 0 <br /> ~ ❑Impcd to U.S. ❑Export from U.S. Port of entr <br /> Transporter signature(for exports only): r;exil <br /> Date[Paving <br /> w 17.Tr Liu ,dgment of Receipt of Materials <br /> Trans artier Pdnkedli Name <br /> CL <br /> b Sl na e M�,ntFy Day Yeay <br /> C.I +r12 �fJ� <br /> Q.Tran porter 2 PrinledlTypP Name <br /> Signa,ure Month Day Year <br /> 1- <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Spare <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑ <br /> Full Rejection <br /> I Bb.Alternate Farah Marufesl 4eferercP Number <br /> _ ty(or Generator) <br /> —J U.S.EPA ID:Number <br /> U I <br /> Facihty's Phone: f <br /> B 18c.Signature ofAltemare Facility(or Generale(! 1 <br /> zMonth Day Year <br /> 19.Hazardous Waste Repor,.Management Method Codes(i.e..codes roc <br /> w hazardous waste treatment.disposal,and recyc ing systems) <br /> o I. 2, 3, J i <br /> I <br /> 20.Designated Facigty Owrer ar Operator:Certirication of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> P*tedlTyped Name <br /> Sgnature Month Daty,� Year <br /> EPA Form 8700-22(Rev.3-0 Previous editions are obsolete. f � <br /> r)F9i NATF3-1�araIivTnr+cc+vr a.. ,.. .._.�. <br />