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Please print or type.(Form designed for use on elite(12-pitch pewnForm ter.) � Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1. eneralDr[D Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C'0 b '73 o$ / 5/$ Cao 5 �o ,�K9' /3 q01 000260941 J J K <br /> Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> cTR 5,m oz o-7 <br /> /6 ;L;fs2 fle,w44NiJ 1ev <br /> Generstods Phone: <br /> 6.Transporter 1 Company N U.S.EPA ID Number <br /> Ant C �',�v/Qo�rnn��v t.9 L Se.P v>cFs �`ni C . C A r2 C5o©© c� / �✓ <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> E,V IE&e q <3)iL <br /> ArCkf r of&. C-4 94.'e.-G o- rte- cl z Z VD 7 y <br /> Facility's Phone: ' / m <br /> ga. 9b.U.S.DOT Description(Including Proper shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codan <br /> HM and Packing Group(if any)) - No. Type Quantity Wt.Nel, <br /> 1. NdN 2Coe 4 14,924 R0&cis "r4Sf� <br /> Ca;t,, W 4 ¢R7 0 519 �.. <br /> Z 2. <br /> W <br /> C) <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information <br /> uS /o2WPe4 PPE <br /> c,e sti/ct ,cs cr rs S�t7 7qc - / 3 4. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and secure*described above by the proper shipping name,and are classillod,Packaged, <br /> marked and labeledlplacarded,and are In adl 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 certify that the contents of this consignment conform to the terms of the attached EPAAdmowiadgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(i!I em a large quantity generator)or(b)(0I am a small quantity generator)is true. <br /> GeneratoeslOff Printedffyped Name S�ignatu -� Month Day Year <br /> t7 G� Il <br /> J 16.Intemationat S I men <br /> p_ ❑import to U.S. ❑Export from U.S. Port of enbrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Trans Ior 1 PrintedrrName Signature ` Month ay Year <br /> CL 1�1I. S6 09 <br /> Transporter 2 Printed/Typed Name Signature Mon1h Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spec ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rajacllon <br /> Manifest Reference Number. <br /> or Generator <br /> 1$b.Altemate Facility( ) U.S.EPA ID Number <br /> J_ <br /> fi <br /> LL Facilitys Phone: <br /> 1 Be.Signature of A larvate Facility(or Generator) Month Day Year <br /> a . <br /> X <br /> N19.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 CaMcation of receipt of hazardous materials covered by the manifest except as noted In item 18a <br /> Printedrryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editlons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />