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Sep 04 09 03: 16p Lindsay Schwager 2099523389 p• 3 <br /> N <br /> Form Approved.OMB No.2050-0039 <br /> please pint ar type.(Form designed for use on elite(12-pitch)rypevrtiter.) <br /> 1.Gene'alor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mande((a�� f)t Tackig Nuro�h JJ <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST ' <br /> Genemror's Sile Adtlmss(.f dlfferentthan mailing address) <br /> 5.Generators Name and Mailing Address - <br /> Generator's Phone U.S.EPA ID Number <br /> 6,Transporter 1 Compatly Name <br /> U.S.EPA ID Number <br /> 7.Tmnsporler 2 Company Name <br /> U.S.FPA 10 Number <br /> 8.Desgrated Facility Name and FAB Address <br /> Facility's Phone: <br /> 10.Containers 11.Total 12.Unit 13.Wash Codes <br /> 9a and Packing <br /> Description(IncludingProper Shipping Name.Hazard Class,ID Number Quantity WINoi <br /> HM ant Packing Group(if anYN No. Type <br /> I <br /> K <br /> QO <br /> C <br /> Z 2. <br /> W <br /> c7 <br /> 3 <br /> 4. <br /> 14.Special Handling Instmctions and Aadbonal Information <br /> . GENERATCIR'SIOFFEROR'S CERTIFICATION: Thereby declare Uel the contents of this consignment are fully and accurately described above by the proper shipping name.and are classified,packaged. <br /> 15 <br /> marked am Ixbe"placarded.and are in all respects in proper condition for transpprt according to applicable international and national governmental regulauons.If export shipment arty I am Ue Primary <br /> Exporter,I certify that lh6 contents of this cormignmenl conform t0 the terms of the attached EPAAckdawiedgment of Consent. <br /> I certify Ual the waste minimization statement identified in 40 CFR 262.27(a)fit l am a large quantitygenxafu}or(b)(fl amasmall quantity genembr)Is true. Monti Day Vear <br /> GenemtorsUffemr's Pdnted/fyped Nana Signature _ <br /> r <br /> 16.International Shipments import to U.S. ❑Eidson from U.S. Pod W entlylexil: <br /> ZDale leaving U.S.: <br /> Transporter signature(for exports Dory): <br /> do 17.Tmnsporler Ackrueledgment of Receipt of Materials Month Day year <br /> W Signature <br /> Transporter 1 Printed/Typed Name <br /> O <br /> Us Monty Day Yex <br /> QTransporter 2 Printed/Typed Name Signature <br /> i on <br /> I � <br /> } 18.Discrepancy <br /> 18a.Discrepancy lndimtian$Pam ❑ quantity ❑Type ❑Residue ❑Parts l Reled!on ❑Full Rejection <br /> P Manifest Reference Nunber. <br /> I U.S.EPA ID Number <br /> 186.Aaemale Facility(or Generator) <br /> I 7 <br /> I V <br /> Fedldys Phone: Month Day Year <br /> w 18c.SIgllatumo(Atemate Facility(or Generator) <br /> a <br /> Fand recycling stems <br /> } y 19.Hannodus Waste Report Management Method Codes(,.a.,.atlas for waste Vestment,disposal, Y 9sY ) 4 <br /> I W 1 2. <br /> 3. <br /> D ' <br /> 20.Designated Facility Omer or Operator:Certification M receipt of hazardous materials cavemd by the manifest except as noted in Item 188 <br /> 1 Signature Monti Day Year <br /> Printed/Typed Name <br /> GENERATOR'S INITIAL COP" <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br />