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t <br /> ipl'e'ase pont or type.(Form designed for use on elite(12-pitch)t� 'ter.) • Form Approved.OMB No.2050-0039 <br /> T UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 7�( 4.[Manifest Tracking Number <br /> � <br /> WASTE MANIFEST �".8-i CS I ��!G7 �� t --I_1 !'.! ; t ^ .{.. z,) (x: $ JJK <br /> Seneralors Name and Mailing Address - - 'Generator's Site Address(if different than mailing address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name - U.S.EPA ID Number.. <br /> R. " -)IA S `C�z2"f itC�f % : " vLViC�` AV2- 1. Ir`t'- <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> y5 �' l`7kF �� Yy !l,'t Uri1�r <br /> Facilitys Phone: - <br /> ga 91r.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12,Unit <br /> HM and Packing Group(if any)). - No. Type Quantity Wt.Nol. 13.Waste Codes <br /> t <br /> 1 <br /> r fw) 6, <br /> Z 2. �. <br /> W <br /> 3. <br /> RE t4TVt=u <br /> 4. <br /> tmY0 17 ' <br /> 4.Special Handling Instructions and Additional Information _... .. ENVIRONMENTAL HUXTH <br /> f,t, PERMIVSEMOOOES <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby deciare that the contents of this consignment am fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condifion for transport according to applicable international and national governmental regulations.If export shipment and Tam the Primary <br /> Exporter,I partly that the contents of this consignment conform to the tens of the attached EPAAcknmledgment of Consent.. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it l am a large quantity generato9pr fb)"lift' m a small quantity generator)is true. <br /> GeneatorslOffamers Printecirfyped Name Siggatdre Month Day Year <br /> =j 16.international Shipments - <br /> r ❑Import to U.S. ❑Export from U.S. Port of entry/exit. <br /> z Transporter signature(for exports only) Date leaving U.S.: <br /> W 17.TansporterAcknowledgment of Receipt of Materials <br /> Transporter 1 PrintedRyped Name.- - Signature Month Day Year <br /> a <br /> Q Transporter Pdntedrryped Name ,Signature - Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type1 ❑ I <br /> ❑Residue Dentist Rejection FuILRe action <br /> Manifest Reference Number: <br /> r 18p.Alternate Facility for Generator) U.S.EPA ID Number. <br /> J <br /> raa Facilitys Phone: <br /> In 18c.Signature of Alternate Facilky(or Generator) Month Day Year <br /> z <br /> 9.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of recelpt of hazardous materials covered by the manifest except as need in Item 18a <br /> Printedrfyped Name Sgnature Month Day Year <br /> t r t <br /> EPA Form 8700-22(Rev.9-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />