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Please print or type.(Form designed form on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HA7ARDOUS 1.Generator ID Number j 2 Page i of 3.Emergeruy Response Phone 4.Yarrtteat Taoldng Nuvrber <br /> WASTE MANIFEST f)k 1.. t( ��''.(....' �: fir; (��•-L 1.tf 015384372 JJK <br /> S.Generators Name ant MAIM Address s Site Address fel tltlerent man m."address) <br /> ... <br /> Generators U.S.FPA b Number <br /> S.Trensporterr er I Compaery Name <br /> ? � l U.S.FPA ID Number <br /> 7.Transporter 2 Company Name <br /> B.Designated Facility Name antl Site Address .7,� <br /> U.S.EPA ID Number <br /> Facifq.Phone: <br /> 9b.U.S.DOT Desaipbon Inducing Pmpan SNpping NarClass.Hazard ss.ID Number, 10.Canlainets 11.Total 12.Une 13.Mast¢Codes <br /> HM and Paddrg GmW(e arrf)) - No. Type Ouamty W1Nu1. <br /> RE N <br /> i Ic <br /> = 2. <br /> w <br /> 3. 0 2 201 <br /> 4. PE IT EMA ^s <br /> 14.Special Handling"Ame tions aMAtldrtional IntormaEm <br /> \ l <br /> I , f s1v� ri r • LLQ <br /> 15. GFNERATOR'SIOFFEROR'SCERTIFICATION:lherebydedme Mattheommnmmn poraigrnrrenl are NH and arnmalely described above by tine proper Shipping name.anlAre classified.Parka9ed. <br /> marked and labeled/placardea.and are in 09 respects in proper wrdibon for Aanspvt acwrdnrg to applicable inte nab"and national governmental reguladoes.11 expod shipment ant I am the Primary <br /> EV,m,•I ,*that the contents of this mnaignm at conform A,the terns of the albrhad FPAAcknow edgnent of Gonsenl. <br /> I certlH that the waste minhn®Eon MIemenl idmged in 40 CFR 26217(a)(t I am a laga quantey generatcO or(b)(tI am a smaY quam8y generator)is tsre. <br /> ;aneatoeslOfleroes NnledlTypd Name Signature Month Del' Year <br /> 16,lnk fllcnal SNpnxnds Dhtb U.S. ❑F on I..U.S. Pat of emyfedt <br /> F- Date leaving U.S.: <br /> z Tansponer slgratam(tor exports only): <br /> W 17.Transporter of Receipt of Materials Month pay YearK Tmmporter l Nniedffyped Name <br /> 2 <br /> Z me Tm.MW 2 Pdmcirryped Na ,` SyaWre Madh Day Year <br /> C <br /> 1Y <br /> r— <br /> } 18.D crelanry <br /> I 18a.Disoe{w+q Idi fon Space OuanNy ❑Type ❑Residae ❑Partial Reject im ❑Full RgecBm <br /> Manifest Reference Number. <br /> r 1Bo.Amemate Faatity for Gerreralm) U.S.EPA ID Number <br /> J <br /> U <br /> sari. FacOdYsPlane: <br /> w 19c.5ig,ature ofAeemale Fadily(c,Gensabr) Month Day Year <br /> Q <br /> z <br /> m19.Hazardas Wask Repod Management Method Codes(i.e.,codes for tarardous waste lreatrnem,disposel,and reeyctin9 ryslame) <br /> w 1 2. 3. 4. <br /> 0 <br /> 20.Designated Facility Owrargpxator Ceff"fim,of receipt of hazardous materials cueerm by the m niesl except as noted in nem 1 B <br /> Pninteciffyped Name SiTow a Monty Day Year <br /> L7 I <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />