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_----------------- <br /> print or type.(Form designed for use on elfte(12-pitch)typewriter.) d.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS Generator ID Number Z Page I of 3.Emergency Response Phone 4.Madi <br /> WASTEMANIFEST � I Z r. r, 00S0760580 JJK <br /> 5.Generating Name and Mailing Address <br /> Generators bft Address(it daterent than mailing address) <br /> Genereat L.Ph0 <br /> S.Transporter 7C.Pi Wr. U.S.EPA ID Number <br /> 7,Transporter 2 Company Marine U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> U.S.EPA ID Number <br /> I ;')q lo-��T jc 1- <br /> P, it <br /> Fadil(a Phone. <br /> St, 91b.U.SDOT Dascripson(Including Proper Shippdngi Nam,Hazard Class,ID Number, 10.Containers 11 Total 12 Unit <br /> . <br /> HM and Packing Group(If any)) No. Tyra Quantity Wt.Nol. 13.Waste Corle. <br /> 1 <br /> 91, Arvnl)kr'i"?, 1'1 Q,117 1 T M S <br /> 01 <br /> Z 2. <br /> s <br /> JWE-z,VE, DENkViF K, A 1,CW:�L <br /> 3. <br /> R CS' <br /> P, -'C-- TEs' <br /> 4. <br /> W,'N—RVf1A WA.FiTE, HOLID <br /> ANI, <br /> K Special Handing Instructions and Additional Information <br /> I J 111f: r+3 4. IIE44)41 <br /> PLAC?'RDS ;'L;r-P BY ��IIGNAVJRE <br /> U,' CALL...; i-!U',T If.,E]TIFY Ull IV'Alk AS r7h ------- <br /> =06 is packa9w, <br /> 15. GENERATORWFFEROICSCERTIRCATION:I hereby declare M the contents of We coni-6106t a—ellrabii W--4. Y��,loerr'shllppl49�.#.�, settled, " I <br /> =*ad and labelediplacarded,and min all respects in propercandition for banspod according to applicable intemationaland national governmental regulations.Ifexport shipment and lamthe Primary <br /> Exporter,I cattily that the contents of the consignment"i to the terms of the attached EPA Acknowledgment of Consent <br /> lcertify thsfltthawasts minimization statuarrentidentified CFR 262.27(a)(IN am largo quannygersersator)or(b)(til nor a small quantity generator)is true. <br /> shu <br /> Generator'slOfferars PftecVTy* m NaSign? nth Day Year <br /> A <br /> j <br /> It <br /> —116.tinernational Shipments <br /> El i or U.S. LJ Exportfican U.S. Pod of Wayrawl: <br /> Transporter signsturn,(for exports ai Date lea%fing U.S.: <br /> 17.Transporter Acknowlectiment of Recept of Materials <br /> Transporter I Prinsidirlypect Name Signature Month Day Year <br /> 0 <br /> Z Transporter 2 Prini %nature Mori6�- tr <br /> < <br /> 4. <br /> ad <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spam ❑ Questity ❑Type ❑Fteiddou ❑Pi Rejection ❑Fut Rejection <br /> 18b.Atemate Facility(or Generator) Manifest Reference,Number. U.S.EPA ID Number, <br /> LL Fai Phone: <br /> 18c.Signature at Alternate Facility(or Generator) Month Day Year <br /> 19.Haeandous,Waste Report Management Method Codes(i.e.,codes for hazardous waste vinamern,disposal,and recycling systems) <br /> 1 <br /> 4. <br /> 20.Designated Facility Owner ur Operator.Certification of mi hazardous materials covered by the manifest accept as noted in Item 1 Be <br /> Pridediflyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COP) <br />