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Form Approved.OMB No.2050-0039 <br /> Please print or type.(Form designed for use on elite(12-pitch)typawdten) 2 Page i of s.Emergency Respar5a 7ncne a.Mani eat TnckinaNumb r (� <br /> UNIFORM HAZARDOUS L Generator ID Number 0 9 G 8 S 7 9 5 FLE <br /> WASTE MANIFEST •"1 �" Q ti U S. 2 $ 3 c� <br /> 5.Generator's Name and Mei ng dress Gararator's Sile Maness(If tlincrem than ma ling address) <br /> x?19: '1151-=4'E <br /> Generator's Phone'. U.S.EPA ID Number <br /> .Transpnrler'Company Name <br /> - - U.S.EPA I'1' be,' <br /> 7,Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.[Designated amity Nareand Sete Address C,L 7•`l -'J 0 Lt 1 :I 3 <br /> Fni tlj s Phone: <br /> 10.Camainers Qu Total 12.Ural 10 Waste Codes <br /> go. 9b.U.S.DOT pasp-ptian(Including Prayer Shaping Name,HazeN Class,ID Number � Type Quantity WWoI. <br /> HM and Packing Group IN any)) <br /> 1�0 <br /> I <br /> OQ <br /> K <br /> 2 2.4--W7 <br /> 3. <br /> i <br /> 4. <br /> I <br /> 14.Spei�Handling Instructions and Ad hotel Information '7F.sF, e.=1 bE FF 'E i- y' pit - <br /> .,fl.�F. �Vc_C%itL Td<,.f.cr 11':J �.....�xfl iii ..... y20E <br /> ria..�. a:r , Idsxe-. C!.C`PiLTi7G <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION:I hereby declare that tla contIcS of is consignment are fully and acturetmy tlesalbetl above by Me propersNpping name,and are classified,packaged. <br /> marked and Wleadlpleoerded,and are in an respects in proper conditon for transport artofdimg b applicable imematonal and nataoal governmental reg�latane.If export shipment and am Ma Primary <br /> Ex net,I ced8y that the content,of this conslgnmem conform to the terms of the attached EPAAcknuv4edgment of Cnsent. <br /> I certify Mat the waste minimization statement Mentfed in 40 CFR 28227(a)in I an a Ange quarmy generator)or(b)if I am a amaN quantty generator)is true. m ay ear <br /> gra iota <br /> GenereW s oror5 Rintetli ype Name <br /> 18.International Shipment 0Import to U.S. Export(tom U.S. Part of enlrylexiC_. <br /> I- Dat leavin U,S: <br /> ? Tran$ (lens nature is on <br /> latex t <br /> 17,TrampdtrAckrmedgnnent of Receipt of Materials onM ay ear <br /> gra m <br /> Fy, rensWrt,rl Pnntetl(fypM Nana I - „ <br /> .,ignature <br /> pit Day ear <br /> Transporter 2 PrinlediTyped Name <br /> H <br /> } 18.Discrepancy <br /> I 10a.Discrepancy Indication Space F-1QuantityType C Residue ❑Farhat Reactor, Full Rejection <br /> Merriest Reference Number. <br /> LLS.EPA ID Number <br /> 18b.,Altenate Facility(orGerleratr) <br /> 7 <br /> LL Fault sPhone: Month Day Year <br /> W 18c.SipnaWre OfAltemate Facility(or Generator) <br /> G <br /> z <br /> 19.H2mmmaS Waste Report Management Methal Crifi.e.,codes for hazardous x'aste treatment,disposal,and reading systems) 4 <br /> ya 1 2. <br /> 0 <br /> 20.Designated Facility Owner or Operator.Certification of femigat of hazardous meWrels mvared by the maSpgdnaWm pt es paled kl Item 1ea Monts Day Year <br /> PnntedRyped Name <br /> GENERATOR'S INITIAL COPY <br /> EPA Form 8700.22(Nev.3 ul Peditionsvious editions are obsolete. <br />