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Please print or type.(Form designed for use on elite(12-pitch) rpewriter.) • Form Approved.OMB No.2050-0039 <br /> TUNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number "'% j <br /> WASTE MANIFEST 'i .> 2 ! p t -�l u U L' 101 '13 8 Ar ! JJ K <br /> .Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ,.:FCFNE.�•(", GC.1�155 p12oCESSIAJG <br /> wGt � )r2 Fav - t�G Tcvv C,A - `Y yo5r <br /> Generators Phone: t "% - •`, (;';^v <br /> 6.Transporter l Company Name - U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA IDNumber <br /> 8.Designated Facility Name and Site Address _ - U.S.EPA ID Number <br /> CCc ( t/r _ � tF77 TV <br /> � x- ?EAT TI/• tc .L/ovA 6700 { <br /> Facility's Phone: jP'• _ $ 1\.) (i I '-/ I <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wtivol. <br /> 1 <br /> QO _ <br /> K ' <br /> W <br /> 2. <br /> W rrl�v„M- <br /> OSI' <br /> 3. <br /> MAY 2 2 <br /> .41 <br /> 4. N ALMUFF <br /> PEMA SEM r <br /> I.Special Handling Instructions and Additional Intension <br /> :tx <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are 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 condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(81 am a small quantity generator)is We. <br /> GeneratorsWemrs Printed/Typed Name Signature Month Day Year <br /> -at 16.International Shipments <br /> F ❑Import to u.5. ❑Export from U.S. Pod of entry/exit.. <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W' 17.Transporter Acknowledgment of Receipt of Materials <br /> K Transporter l PrintetllTyped Name u. Signature: - Month Dav Year <br /> O <br /> a <br /> zQ Transporter 2 Pdnted/ryped Name Signature Month Day Year <br /> K <br /> r <br /> jIS DiscrepancyIfe.Discrepancy Indication Space ElQuantityType ❑Residue ElPartial Rejection ❑Full Reection <br /> Manifest Reference Number. <br /> r 181c.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> n Factilys Phone:'' <br /> Ma 18c.Signature of Alternate Facility(or Generator) Mont Day Year <br /> Q <br /> 2 <br /> `9.Hazardous Waste Report Management Method Codes(i.e.,woes for hazardous waste treatment,disposal,and recycling systems) <br /> L 2. - 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdntedrtyped Nhi Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-11) Previous editions are obsolete - DESIGNATED FACILITY TO GENERATOR <br />