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Please pr1it or type.(Forri designed for use on eine(12-Pitch)tyaewriter.) <br /> UNIFORM HAZARDOUS 1.Generator D Number I2.P e r of 3,Erne FormAppnoved•OMB No.2050.0039 <br /> WASTE MANIFEST c(� �(j� � �'9enc7`Responsfe,1 <br /> or* Ifeet eking Number <br /> � � eelt ag, GBF <br /> 5.Generators Name and Mailing Address Generator's i:e Add est ddress) <br /> .6.Transporler 1 Gompa y Name <br /> U.S.EPA ID Number <br /> cCGc�U z <br /> 7.Tramsporter 2 Co Name <br /> U.S.EPA 1p Number <br /> 8 Deslgnaled Facility Nems andtedr l <br /> �'t9-vLtM'�, •,�.=...e- n('.v,4. l""' �lr`,� u:s.EPA ID Number <br /> r� � ['�,.C�e1� c 7—s t <br /> Facilitys Phpne:4S�l.k — <br /> 9a, 96.U.S.a07 Description(including Proper Shipp ng Name,Hazard Class,to Number, 10. ontainars <br /> HM and Packing Group(dant}) t1.Total 12.Urct <br /> No. Type Ouar lty 1NtlYd. 13-Nlas'.a Codes <br /> ,. W r <br /> i <br /> LU <br /> i <br /> AUG 0 6 2016 ' <br /> t- <br /> d. <br /> ENVIRONMENTAL HEALTHra a Ill FLIT <br /> I �� <br /> 14.Specht Mandrin;Instructions I f - <br /> 4f- OfPPE <br /> 1 S. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this oorsignment are fully and accurately described above by the Draper shipping name,aid are rdassified,packaged, <br /> marked and faboledlpfararded,and are m all respeds in prooercondRier for,ranapDrt according to all intemador'si d 'nsi mmemai regulabans.If export shipment and i am the%many <br /> Exporter.d cartify that ft contartrB of Ws consignment conform to the 18nns of the attached EPAAdcnovledgrient of Con <br /> I calft tnat the waste minimization atalemilintiderliffed In da CFR 262.27(a)(if'arr a Ii quantity gene ator)ar[b)( a all n 98MrWQr,l5 true. <br /> Gen 0 sRn' Na a Signature !1 Month Day Year <br /> r <br /> FJ- 16.Int ahonal Shipments [ <br /> import to U.S. Export from U.S. o o /lexrt _ <br /> Transportersignalure;for exports anFy)_ Cate ngl`.5.; - <br /> tY 17.TranspaterAckrmv,edgmerM of Reraipt of lr'atedals <br /> :�)Tran orer 1 Prinlodffyped Name Signahs Mcnth pay /Year <br /> CL <br /> Transporter Pirtndl d Nams Signature Mcrih day Year <br /> a <br /> H <br /> T8.blsorepancy <br /> 18a.Dlstxepancy Indication Spew Ll --r <br /> OuantN ❑Type Residue ❑Partial Rejection Q <br /> Full Reje'ttian <br /> Manifest Reference Number: <br /> 186.Alternate Facility!or Generator) U.S.EPA 1D Number <br /> J <br /> U <br /> a Faci ity's Phone: <br /> H16c.Signature of Alternate Fadllty(Dr Geri lor) Iii Day ,'ear <br /> d <br /> 1 S.Hazardous Waste Report Management Method Codes'i.e,codes for''azardous waste treatment,eisposal,and racyding systems} <br /> f 2. g, 4. - <br /> 20.Designated Facility Owner or Cpernfor.CerBBcatior,of receipt of hazardous materials covered by the manifest except as ndec n Item 18a <br /> nn edrryper Name Signature Month Dav Yea- <br /> EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. <br /> DESIGNATED FAl TO DES-11HATION STATE(IF REOUIRED) <br />