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III ITT -IT ITT <br /> Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved, OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone r7Wli <br /> Tracking Number <br /> WASTE MANIFEST C A 0 99 to � Ifi m p 9 4 'I. � �£���t�P 4 '? 4_<3 '31�. 0 12 8 17 JJ K <br /> 5. ene r' N a d„tyi 'li Ad My <br /> Generators Site Address (if different than mailing address <br /> LA <br /> �-*y ,fly',+a'4 'tl r�P.;l"Wol ROAD d 1 <br /> LAy Mia ir � •�� .� JFSlt:FfL i��k�� f- i''� �1�$'i .30E` <br /> Generator's Phone: <br /> 7. Transporter 2 Company Name tl S-_EWnumbe <br /> 8. De q ci r e n tt , d s U.S. EPA ID Number <br /> WS S fel+ G L l ,vi Ci a ? ;:t t!32 3127 74500 C A M1 0 D a` � :a 9Faciliys Phone: <br /> ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> HM and Packing Group (if any)) No. Type Quantity WtJVoi. 13. Waste Codes <br /> 1 . <br /> o 3'O '•.f aha RA HIAZl� ��: US ASI <br /> W21IT <br /> 0 <br /> 3: <br /> i <br /> i <br /> 4 <br /> I <br /> 14. Special Handling instructions and Additional Information <br /> kl ll x�, Af PPX� E;? C, SVIVE P o : A1';b01 '#'990 'H APPI PIRIA` f-0 PE ' NI MfYK FIVP t0ills•°ME"T <br /> 15. GENERATOR'SIOFFEROR'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 labeled/placarded, 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 consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certily that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br /> Generators/Offeror's Printed/Typed Name Signature Month Day Year <br /> IT <br /> all <br /> -� 16. intemafional Shipmentsr <br /> ►— ❑ Import to U.S. ❑ Export from U.S Port of entry/exit: <br /> z- Transporter signature (for exports only): Date leaving U.S.: <br /> LM 17. Transporter Acknowledgment of Receipt of Materials <br /> FTransporter 1 Pr nted/Typed NameSr natureTe <br /> a 'r ' ' 9t.44"I 111 MonthDay Yearrsznsporter 2 Printed/ Typed Name Signature V Month Day Year <br /> F- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ quantity ❑ T e ❑ Residue <br /> YP ❑ Partial Rejection ❑ Full Rejection <br /> y Manifest Reference Number: <br /> I= 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> V <br /> Q <br /> Li. Facility's Phone: <br /> W 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> z <br /> N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> LU <br /> 1 2• 3. 4• <br /> 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedlfyped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />