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r <br /> + Please print or type.(Farm designed for use on elite(12-pito writer.) Form A� PProved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.tPage 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C. t"\�v. .;'^s _..t `7S'"l.,f.� i ".�}' "..': .y 1,; \':� Ono 8065 <br /> 1 2 G B F <br /> 5.Generators Name and Mailing Address �Generators Site Address(if different than mailing sail <br /> dd <br /> ,Ylc. i. :3, c��"t'<. :y.� 4�','� ,'(`fit�+`•'r > �t�.:\^. "t \'•-� w. h <br /> Generators Phone: ^+ bxi T1 <br /> fi.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> AL I <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facifity's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLN01. <br /> {a 352 <br /> Z 2. <br /> w <br /> SIT <br /> r, <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately absorbed above by the proper shipping name,and are dassified,packaged, <br /> marked and Iabeledlplacerded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I partly that the contents of this consignment condom to the tens of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)('d I am a large quantity generator)or(b)(dl am a small quantity generator)is true. <br /> GeneratorsrOReroes Pnnted7Typed Name Signa / .� , Month Day Year <br /> • f y°'-.,/ /`;i. � '.'�?( <br /> J 16,International)Shipments l' <br /> F El Import to U.S. El apart from U.S. Port of enuylexit: <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> EliT r 1 Printedfryped Name or Month Day Year <br /> CIL <br /> �} <br /> Z Transporter Printed/Typed Name Signature Month Day Year <br /> K <br /> 1-- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fadiib/s Phone: <br /> w 18c.Signature of Alternate 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 /> D 1' 2. 3, 4. <br /> 20,Designated Facility Owner or Operator:Campos on of receipt of hazardous materials covered by the manifest except as noted in Item Ise <br /> Pnnledrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> 51aJ9 L GENERATOR'S INITIAL COPY <br />