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7 ;{.. <br /> Please print or type.(Form designed for use on elite(12-pitch)rg triter.) form Approved.OMB No.2050 0039 <br /> 1.Generator ID Number : ' 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number ; <br /> UNIFORM H,4ZARDOUg ., ,, ,,M, A ,: a, <br /> �:. <br /> WASTE MANIFEST 1 .J'� _ C,:= "':'.,._-, ('=a"'r f, <br /> 5.Generators Name and Mailing Address Genoratdrs Site Address(if different than mailing address) <br /> r.:� fx� �'uLCc.1ki iL ! �rti . _�C5 s.,• � �: <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> " - ::'s ail': a�..-rj;c,, ��a _ _ .n�. - `-''::�'�_-{`'x fi•}`,��'="+.�'i <br /> 7• P Company Com an 2 Transporter - <br /> Trans Name U.S.EPA ID Number <br /> B.Designated Facility,Name and Site Address U.S.EPA ID Number <br /> TI- <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard C€ass,ID-Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.NoI. <br /> -._,F'.{ezt '{ ':.i:,- a.'?� ;1'.'i,. .�! F'''i p--LJ1 ' <br /> •. s., L <br /> f� <br /> Z 2. <br /> LU <br /> 3 �rt <br /> 14.Special Handling Instructions and Additional Information _ �} <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and acwrafely described above by the proper shipping name,and are classified,packaged, - <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable intemational 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 terns of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)('d#arrl�1 a quantitygenerator)or(b)(if I am a small quantity generator)is true.' <br /> Generator_slQfferofs Pdnted/Typed Name e. Signaturex Month Day Year <br /> o` )f <br /> 16.International Shipments <br /> ❑Import w U.S. ❑Export from U.S. Port of entrylexh: <br /> Z Transporter signature(far exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Uj <br /> Day. <br /> � Transporter f PrintedfTyped Name Signature Month�• - Year <br /> p <br /> h y� i Y" <br /> Z Transporter2PrintedlTyped'Name Signature Month Day Year <br /> 18.Discrepancy <br /> 1Be.Discrepancy Indication Space ❑ Quantity ❑Type [:]Residue ❑Partial Rejection ❑Full Rejection <br /> a Manifest Reference'Number: <br /> 18b.Altemate Facility(or Generator) ,U.S.EPA ID Number <br /> J <br /> V <br />€ LL Facilitys Phone: <br /> QMonth Day Year <br /> LL, 18c.Signature ofAltemate Facility(or Generator) <br /> Z <br /> S219.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 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 I Be <br /> i <br /> Printedlfyped Name Signature Month Day Year <br />{ EPA Form 8700-22(Rev.3-05) Previous editions are.obsolete. <br /> GENERATOR'S INITIAL COPY <br />