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Ptease print or type.(Form designed for use on elite(12-pitch ,pewr!1er) Form Approved:OMB No.2050-0039 <br /> UNIFORM HAZARDOUS1-Generator It)Number 2.Page 1 of 1 3.Emergency Response Phane 4.Manifest Tracking Number <br /> wASTEMA�IIFEST SIa)2�-01SL1 0 0 5 2 3 2 3 2 4 JJK <br /> 5.Generators Name and Mail Q Address �f Generators Site Address(4 difteteht than marling address) <br /> V �*3 avG 0P,,Z 14b4-Lot-),Tvin�r4rfir L-,L-S 5 <br /> P•C�.fSC1`� It{�iC1 �ai� les�wl�j <br /> Generators Phone. <br /> 6 Transponar 1 Company Name U.S.EPAID Number <br /> m0lac-]AL7 IL� t Chi Ort 13u $ <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Desrgniled Facility Name gild Site Address -1 .r r„�y ��,}� U.S.EPA ID Number <br /> l( PCs kx:) t V-r�-1 fit" <br /> FaolnyaPhone; <br /> ga. 9b.U.S.DOT[Description(including Proper Shipping Name,Hazard Class,iD.Number, 10.Conlaine.m 11.Tota: 12 UnK <br /> fiM and Packing Group(If any)) No. Type Quantity Wt.Nol 13.Waste Codas <br /> , .tU+i51[•; �' �'r'+'1l C, ��C.. 1�� � t�`SaZ' <br /> 2)30 <br /> 31 <br /> 2.00R,-,) wbsi- e=,X�S <br /> �i OQ <br /> � r <br /> 4. <br /> 14.SpeGoHxrdflr.hatters!ions.3n1!PddiGanallnformatfon - <br /> xX! n�"'�f- -cst�.�. tst �aal.►C'�c�.. `SSS <br /> C, <br /> 15. GENERATE WSA)FFEROR'S CERTIFICATION:I hereby dedase trial the contents of this eon!4Wmenla(e hiMy and a=wstely described above by tie properstipping name,and are classi5ed,packaged, <br /> marked and tabeladlptaprded,and are in altrespects in proper condition for transport aCCor1ft10.fo*pl le intemadonal and national govefninental reguiatiorrs.If e%ponshipment am I am the Primal <br /> Exporter,I aeitlfy.)hal The contents of fens consignment conform to the terms of the adachOd EPA, grrrattt orConsent. <br /> !cr�idy OL@atre waste nn Nmifaton st8tement ider.fled In 4D CFR 262.27(a){if l am s large )on(b)(if I am a sma l quannlygenerator)is Lue. <br /> Generaloi'sr WoLs=pdnledffyped me store. Month Day Year <br /> t 16,thlem Sona'Shipment <br /> rz ❑Import to U.S. ❑Expdd from U.S. -Port at erjhylexit._ <br /> Transporter signature(Ic r exports only); Dela leaving lf,S.: <br /> W 17.TanspatorAdtnoNledgmenio�fReceiptofMatedals <br /> TranspdRe tedlTyped N Ssjnaku s Month Cay Year <br /> EL <br /> cn <br /> l 22 f <br /> T, er nnl yped Name Slgnatu Monlii Day Year <br /> t8 R;istis±pancy' <br /> iSa Dlscrrpancy Inodtaticn Space '❑ quantity Ll Type ❑Residue E,J Partial Ra;ection ' 1 Full flection. <br /> _ Manifest Relerence Number. <br /> Ttib.AhWpla}a Facilny(or G n*iraturj _. U.S.EPA ID N'ymter - - <br /> U <br /> t`ti aci lys Phone: <br /> 18C.Signaftre ofAllensale Faalrty(or Generator) man" <br /> day Year <br /> 19.Hazardous Waste Report Ma nagarrrBtrt Malliod Cones jr.e.,cartes foi hazard us waste treatment,d sposel;and raaycing-yWerrss) <br /> U.1l. f f 2. r 13. G. <br /> 20.Des ed F 'rty Owner or Operatoc..CerLllieation of receipt of hazardous matelots covered by Me manifest except as ded in lte a <br /> nn me SiglraNre Month bay Year <br /> ✓'� t i? f N <br /> EPA Form 8 -22(Rev.3--05) Previous editions are obsolete DESI A'TED FACILITY TO DESTINATION STATE:(IF REQUIRED) ' <br />