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Piease print or type, (Form designed for use on elite (12 -pile <br />UNIFORM HAZARD DUS 1. Generator ID Wrnhar <br />WASTE MANIFEST <br />5. Generator's Name and Mailing Address <br />Ganeralor's Phone: <br />5. Transporter 1 Company Name <br />7. Transporter 2 Company Name <br />8. Designated Facility Name and Site Address <br />Facility's Phone: <br />2.. <br />3. E.morgonry Rospnrao PI <br />3onnralor's Sha Addross {If r <br />Form Approved. OMB No. 2050-0039 <br />Ing Number <br />SKS <br />U.S. EPA ID Numher <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Conlalners <br />11, Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />13. Waste Codes <br />No. <br />Typo <br />Quantity <br />Wt./Vol. <br />1. <br />2, <br />w <br />0 <br />3. <br />Cr.ori�l <br />4. <br />Lf�.,.l[In.. Inelni..li...... —A AAA:-- I I_(--__,:__ <br />15. GENERATOR'StOFFEROR'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 labeledlplacerded, 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 certify that the contents of this consignmenl conform to the terms of the attached EPA Acknowledgment of Consent. <br />f certify that the waste minimization statement identified 'in 40 CFR 262.27(a) (if i am a large quantity generator) or (b) (ff I am a small quantity generator) is true. <br />Generalor's/Offeror's Prinled/Typed Name Signature Month Day Year <br />� 16. Internafonai Shipments <br />I— ❑ Import to U.S. ❑ Export from U.S. Port of anlrylexit: _ - <br />Z Transporter signature (for exports only): P R Y): Delo leaving U.S.: <br />W 17, Timwpudvl Acknuwlndflment of rNbrWpl of Mutuliulc <br />Transporter 1 PrInIed/Typed Name Signature <br />R Month Day Year <br />TranSaeder 2 PrintedlTVDed Name <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ QuantityTYPe Residue <br />❑ El Poi Rejeutiun ❑ Full Rejectinn L_ -_I <br />18b, Aiternale Facifity (or Generator) Manifest Reference Number: <br />U.S. EPA ID Number <br />t� <br />Facility's Phone: <br />Signature of Aitemate irar.iiity it, s3Hneialuo Month Day Yaar <br />C <br />rardcus Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling syalems) <br />[a 1. 2. 3. 4, <br />20. Designated Facility Owner or Operator. Gertifonation of reneipt of ha7nrdnn5 materials cowered by the manifest except as need in Item 1 Ba <br />Plhrledffyped Name gni ure Month Day ear <br />EPA Fumi 8700.22 (Rev. 3-05) Previous cdltlons are obsolete. Y ,C t1Yl 14A'1'0r?79 In1f t rnr r1nr7v <br />