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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Ngmb�r 2.Page t o` 3.En�r�asncy Iles nse Pha a 4.Manifest Tracking Number <br /> WASTE MANIFEST t ? ,91iI,r 7a e 4 ; ; a ;, r- -i;). °, #. <br /> 5.Gp efator a e an�r{i I!a ling Address. F. <br /> i4lt' t}. .rti�,r{�z � 016020445 JJK <br /> e�err <br /> �}iato(sSite Address(ifdifferent than ma�ngaddress) r <br /> ' ,� , { •k'.j1 t ,( ',l'.ixfr• <br /> �.'` {.irl_- }��� t� s�1°px3�;1 f4;Yts !.✓4A'g� o Ak. N'y ..AD?i <br /> Generators Phone: <br /> 6.Transporter 1'Company Name U.S.EPA ID Number <br /> '4ird+re !Ub1Si4:1YopJ V ?.; >t$'.tif 2f1 IIr1r". I`..A'1 !478} <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B;De�$nqtedfpity.NaVia Site Address U.S.EPA ID Number <br /> :It'/:139 <br /> Facility's Phone; <br /> ga, 9b.U.S.DOT Description(Including Proper Sh!pping Name,Hazard Class,ID Number, 10.Container 11.Total 12.Unit <br /> HM and Pacing Group(if any)) 13.Waste Codes <br /> No. 7y pe Quantity WlNol. <br /> 1. Ati{:k9 firf;9$t `i *.!r-tN.ntti '?9l$:17 {tJ4:w1?0.. •filiftrstj!IffOt..r;'a't1 <br /> w <br /> LU <br /> 2 Axa 11r,itwl fYT;sx;r,x:��aaanix `i.'1b113, x"sr�Xi>!c9 ? ztyal.kr 7;y:9:k <br /> tD <br /> 3. V.t:, i <br /> 4. <br /> 14,tSpecleiMAjd (!1s $and AdAR It rf$ 'o m1?'&?a sl''.I4'3izn) wj Y1 if3.$:t3?:e8i111 <br /> 0 til, #;tu �.; # r3,t >,x:?T; 9z' x i .ti3rl;i .►a1 's pyres kYr-kwo oi. <br /> rt'?�' ���f�+� kS>: 4_a�lk:.i':a�iztF! �r"t;te7xP��'�T::��,: fiir�Y�S•:1�i9biy;7's9 t� .k+tt'�ti'3)ty�{�it3� ti _ <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 dassiFed,packaged, <br /> marked and labe!edlplacarded,and are in all respects in proper condition for transport according to applicable Intemational and national governmental regulations.it export shipment and I am the Primary <br /> Exporter,I certify that the contents of this cohs!gament conform to the terms of the attached EPAAc'tn Medgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(H I am a large quantity generator)or(b)(if t am a small quantity generator)`s true. <br /> Generatoes!Offeror's Printedliyped Name Signature <br /> Month Day Year <br /> -r 16.International Shipments <br /> F- ❑Import to U.S. ElExport from U.S. Port of entrylexit+` <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TransporterAckna;ledgment of Receipt of Materials <br /> 12 Transppner.1 Pdntedrryped Name Signature �� Month Day Year <br /> Zd <br /> Transporter 2Printed/TypedName Signature j M,onih Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space E ❑Type ❑Residue Qua�ti EllPartial Rejection ❑Full Rejection <br /> r <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> #a+ Fedlityrs Phone: <br /> C3 18c,Signature of Alternate Facitity(or Generator) Month Day Year <br /> Q <br /> r9.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LUo T.- <br /> 2. 3. 4. <br /> 20.Designated Facility Csner o•Operator.Certification of receipt of hazardous materia's co':ered by the manifest aX pl as nded in.item 18a <br /> Printed/Typed Name Signature I'.:onlh Day Year <br /> EPA Farm 8700.22(Rev.3.05) Previous editions are obsolete. <br /> GENERATOR'S INI"t'IAL CONY <br />