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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 7 at 3.Emergency Response Plane 4.Menneat Tracking Number <br /> WASTE MANIFEST G 0o0 ` (P' l ' D$� 010875072 JJK <br /> 5.Gerioalors Name and Mailing Address Generators Site Address(if relevant than mailing address) <br /> P-GS ReFinIY1 .3 <br /> Zz-zz S.SheLa,rave- --4vck-4vvi 64 <br /> Generators Phone: OTS R5 I <br /> 6.Transporter 1 Company Name US.EPA ID Number <br /> ec- C>4p r�o3 Sq <br /> 7.Transporter 2pony Name U.S.EPA ID Number <br /> 8.Designated FaWityN eand ite Address U.S.EPA ID Number <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.C22U! s 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity WWaI. <br /> g N one( Mon RCRP-q4 zavA DU.S L jeq fe' <br /> 60�i� Ia�bS Lemma 8 <br /> z 2. <br /> 3. <br /> 4. <br /> I <br /> 14.Special Handling Instructions and Atldi"Information <br /> ,. Er(— buelcecl mirror 6441 (C' ff6D3�9� �d��'� <br /> ey <br /> 15. GENFRATOR'SIOFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and aetoafely,described above by the proper shiyping name,and are classified,packaged, <br /> marked and labeledlplecarded,and are in all respKis in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of Nb consignment anlwm to the terms of the attached EPAAcknowledgment of Consent. <br /> I ceNly that the waste minimization statement identified In 40 CFR 26227(a)(f I am a large quantity generator)or(b)(if I am a small qua"genealor)is true. <br /> Genes snOlerro 'nledRyped Name Signa Month Day Year <br /> [Q 117 I <br /> 77 16.International Shipments <br /> j._ impodto U.S. LEvort from U.S. Port of entrylexil: - <br /> Tampoder signature(for exports only): Data leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materiels <br /> Transporter 1 PrntedrFyped Name Signatum Monty Day Year <br /> 0 p n <br /> Transpmter2 Printed ype me 7 7'( Ytr'T, gnalure MopN, Oay Ye r <br /> 1 18 Otscrepamy <br /> 18a.Discrepancy Indication Space Quantity i!°•.�.Type c ❑Partial Rejection ❑Full Rejection <br /> i � erence Number: <br /> 18b.Altemete Facility(or Generator) U.S.EPA ID Number <br /> 0 Ei1fViROPJN!£9!`1 AL HfF i(-7th <br /> sae. Facility's Phone: <br /> m 18c.Sgn*a ofAttemate Facility(or Generator) _ Month Day Year <br /> a <br /> a <br /> w19.Hazardon Waste Report Management Method Caries(i.e.,modes for haiartlous waste lrealmenl disposal,and reading systems) <br /> 1. /3t7` 2 3 4. <br /> 20.Designated F erar Opemtor:Certification of gif6ptirrhicairdinus mahmals covered by the manifest except as noted in Item Ise <br /> pryrtedlTypaO Signature Month D y Year <br /> 9/ <br /> EPAFoon8700-22(Rev.3-05) Previous Orlions are obsolete. iiESIGNATED FACILITY TO DESTINATION STATE(IF RE IRED) <br />