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PIP.ase print ortype.(Form designed for use on Hite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Gaterala ID Number 2.Page 1 d 3 E Res Form APP�ed.OMB No.2050.0039 <br /> WASTE MANIFEST !^ 7 K• �f f ( verse Phone 4.ManlhM iraddng Number <br /> SGerantays Name and MaiNg Adtlress ' �` ! 7. �c -, ; 015384304 JJK <br /> s Adhess(d di0eradtYan magmg aedess) <br /> ..� :. . t :�i' i. M� I F� (-71i/l. 7 CCN= 1 L: r✓ [-+ "tom ,..I rJ <br /> Ceneratofs Phone: <br /> 6.TamInD ta•1 COmpanny Now <br /> U.S.EPN ID Number <br /> 7.Transporter 2 Comp"Name <br /> U.S.EPA ID Number <br /> 6.Designated Fadity Name and Site AGhess <br /> U.S.EPA ID Number <br /> 7 71 <br /> FWWs Phone: �•• _ r 1 :v <br /> 9D.us.Dor UT "2f.Ul U:�oU <br /> 9a. Desm0on(Including PmPer Snipping Name,Hamrd CJass,ID Number. 10.Codaiirota <br /> NM and Packing Getup(Karry)) 11.Trial 12.Udl 13.Walk Codon <br /> 1. No. Type Ouamay WtN <br /> � /x <br /> Z 2. `�` i 7� �w .� ✓a ( � p <br /> u, <br /> 3. <br /> r <br /> 4. <br /> AL I <br /> 14.Special Handling MsNatiom and Addional rotomadon <br /> rei:. C ' �c <br /> 15. GDIERATOR'SIDFTTRORS CERTIFICATION: Iharebyy deGam that the oortans d this cortsignmed afulyaM amaaky desrn'hedaWvabythapmper shipping nacre,ardsm desslled,packaged, <br /> marked and IabekWplacadsd,and are in all respells in proper condtion Mrtansport according to applicable ram aborml and nationalg oremmeMal <br /> regurotios.if-Portshipment and m me Primary <br /> Eywrter,lcertify mal me mnkms of min coring;anent mnbrm bMeterms o(be alkd�ad EPAAckrwMedgnentdCwsed. <br /> I Gamy that the waste minflIM KM sktement dw fied in 40 CFR 26227(a)(I l am a large qt ntitygeneadr)ar(D)(dl. a siren quantity generaror)is tne. <br /> Geneatoes0themes Prmkdrryped Name_ Signature <br /> 1,-. 1. ,V �,r / .r,Z `. i / Monet Dey Year <br /> fTma-sT�PD�rt. <br /> bDnal Shpment5 ❑Ezw f.U.S. Pod ofedrylenter simmers(for esperes only): <br /> n I Pninted/ryped Name <br /> Sgahre MoMh DeY Yoa 2 RntaNTyped NameSignaWreDay Year <br /> 16.Discrepancy <br /> Ise.Dsaepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Refection ❑FW R*cb. <br /> ( <br /> 166.Alkmak Fadlity(a Genrraror) Manifest Rabrence Number. <br /> U.S.EPA ID Number <br /> J <br /> U <br /> I Facililys Phone: <br /> W 16c.Sigroke ofAlkmade FaaTdy(or Generator) <br /> F Monet Day Year <br /> Q <br /> 2 <br /> 19.FaaMous Waste Repan Management Wood Codes tl.e..codes M ha>ardous xaste tmabram,dapocal,and recythng systems) <br /> o I' 2. 3. 4. <br /> Z0.Designakd Fackly Omer or Operator.Geri flee of 2ceipl of haxarddis materials covered by ds manifest except as noted n Itt.n Ilk, <br /> PnntWyped Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />