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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 Number 2. Page 1 of 3. Emergency Response Phone4. Manifest Tracking Number "` <br />WASTE MANIFEST 0 8 7 0 3 "G B F <br />5. Generator's <br />Name and Mailing Address y �y { Generator's Site Address (if different than mailing address) <br />Pail t. Yltwk`fl � rjI ll* t 451 6 0y f'iR <br />9111.11 El GIVIPT", 4 �� <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />t''r�tl'a"�tj�il�'�rFh`Pi'tlL3YS:f3 4a��P,C�iE>>�$�, 1fPR, �'f!1'rt3� s'�f'3Y•`tt`3".":�,'r.'�:r� f,«fi['�1�'�t;''Ir <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. DesirgaledFacility Name and Site Address U.S. EPA ID Number <br />fftitluA,tlSi i. k fd1v.. <br />Duro-m}h kwa' l,,ofl tt;"4gl <br />FacilityrsPhone: 581-&4•91ZA <br />ga• 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, (D Number, 10. Containers 11. Total 12. Unit <br />HM and Packing Group (if any)} 13. Waste Codes = <br />No. Type Quantityt-� Wt.Nol. <br />1' t4M ftPA t-bnfr oa4 L"4, 0j, I i+}1Jt:. -My WAI'(jwt" f "^j � V r 'I <br />Ll] <br />Z 2. <br />w <br />t.7 <br />3. <br />4. <br />14.S i I Handling Instructions and Additional Information <br />e•I$n��]rtti� dfr �'st'a�?r8� `�5ti'k' �t.11P � . <br />15., GENERATOR'S10FFEROR'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 fn proper condition for transport according to applicable international 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 EPA Acknowledgment 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 />GeneratorslOfferoes Printedfryped Name Signature Month Day Year <br />j 16. International Shipments ' <br />Z ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit <br />-- Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />LA <br />OTransporter i Printeppd/Typ}ed Name Signature ,. Month Day Year <br />Lill <br />a Transporter 2 PrinledlTyped game Signature ( Month Day Year' <br />EL' ' <br />H <br />18. Discrepancy <br />1Ba. Discrepancy Indication SparcElPartial Re <br />❑ Quantity E] Type ❑Residue; - l ❑Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator} <br />J U.S. EPA ID Number <br />U � <br />facility's Phone: <br />w 1 Bc. Signature of Altemate Facility (or Generator) Month Day Year <br />a <br />Z <br />y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />© 1' 2. 3. 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintediTyped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. <br />GENERATOR'S INITIAL COPY <br />