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i Form Approved,OMB No.2050-0039 <br /> Please print or,type.(Form designed for use on elite(*pitch ewriter.) PP <br /> 1'.Generator iD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIF04M HAZARDOUS G B F <br /> WASTE MUWIFEST IL <br /> 5.Gener for s Name and Mailing Address Generates Site Address(d amereTii than mailing address) <br /> �tt �. . ),L�'F"i ..1::>.'t= 4:'rte, ; w "-f•,`::, _ <br /> Generator s phone:, :'a'h i - U.S.EPA ID-Number <br /> 6,Transporter 1 Co pany Name <br /> 7.Transporter 2 Compari¢Nahte 'k :_ <br /> U.S.EPAfDNgmbb���ffy.4z" <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> �' �` " Al'-41� '' <br /> -x <br /> T. <br /> FacaGty's Phone: - <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,.ID Number, 10.Containers 11.Total 12.Unit ' f3,Waste Codes <br /> 9a. No. Type: Quantity Wt1Vol. <br /> HM and Packing Group(if any)) , <br /> OtY�!' 6\'•_.�" : i"'_:i 'f'r °:3tti.� '1G'rfS -w ; <br /> Uji - - - - <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this oonsigdment are fully end accAfely described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,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 Primacy <br /> Exporter,I certify that the contents 61 this consignment conform to the terms of the attached EPAAckncr0edgment of Consent. „ <br /> l certify that the waste minimization statement rdenffied in 40 CFR 282.27(a)(if I am'a large quantity generator)6r(b)(if l am a small quantity generator)is true. <br /> GeneratDrslOfferors PrintedlTyped Name <br /> Signature; = Month .'Day'., Year: <br /> J tin.Intemattonal Shipments Import to U.S. Export from U.S. Port of entrylexitt <br /> Date leaving U.S.: <br /> Transporter signature(for exports only): .. . . <br /> w 17.Transporter Acknowledgment of Receipt of Materials Month Day Year <br /> C) Transporter 1 Pnnledffyped Name Signature - .. <br /> Month Day Year <br /> z Transporter 2 PnntaOyped Name SignaturAw <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Q Type_ Residue Partial Rejection Full Refection <br /> 0 Quantity <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) .. . <br /> ra Fadlify's Phone: Month Day •Year <br /> LO I8c.Signature of Ailemate Facility{or Generator} ' ::�:_ <br /> a 4: <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator,Certificafion of receipt of hazardous materials doverod by the man fest except as noted in item 18a Month Day Year <br /> PrintedlTyped Name Signature <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. f:ENER01'OR'S INITIAL.COPY ` <br />