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• jF • 77­ <br /> Please print or type.(Form designed for use on elite 12-pllch venter. ' Y Farm Approved.OMR No,2050�003g � <br /> 1.OeneralorlDNumbor 2.Pagetol 3.Emergency Response Phone 4.Manifest Trackingumber �g <br /> UNIFORM HAZARDOUS qt('{ �} .• <br /> WASTE MANIFEST (.+true3>?477 i C,1 C.1 4 3 4 0 e-0 7 <br /> S,Genendefs Name and MadngAddress GeneraWs9tePddress(ddigerent then ma9ingeddress) - x <br /> r :"It I I 0I::00A(IIII It0. <br /> Genoetoes Phone: Vj) ii16 COX, .. <br /> B.Transporter l Company Name U.S.EPAID Number <br /> i�.':hii 1' IjI:I.II tl1 I':.ti°.1•I t1 L ('KsACU4, 1610 t '•;OC'd 1°a;.: , <br /> 7.Tramponer2 Company Name U.S.EPAID Number , <br /> I i <br /> I I <br /> e.Oesignpted Fa�ytv.N�r�l?anntld ySg9 ppadddres{. U.S.EPAID Number <br /> 191': ::"t.r�hJt9i.RO.AU <br /> y,P._;;I'.^,:.QIt�.Cdii191 Cr,i-i.,•: �5{i11 <br /> Fadli 's Phone: 'Iif;.,;:1,51.1 <br /> ga. Sb.U.S.DOT Description(indult ProperSMpping Name,Hazard Gass,ID Number, 10.Containers 11.70181 V.Unit 13.Waste Codes <br /> HM end Paddrg Group(deny)) No, Type Quaray, WL/Vol. <br /> _ 1. I!ilfl r:i:f:A.1r.7t•,l ilhi!J.i WASTE l.lt}y!D (y}p.Y\Vv';rid'n:} 2:1f <br /> O <br /> 2 <br /> 3. <br /> 4. <br /> 14.Spechal Handling InsWCCeits end Addition311nfonnabon <br /> !itf 1)II RIVIIJ:t4 11110:r9'II Ntyldtll.GRE- 9H(J1)IJ)IJr? )};h1(•1BCI ANTI111",t?ArlptUoi.1011='ia!„ <br /> 15. GENERATOWSIOFFEROVS CERTIFICATION:I hereby declare that the contents of this cerslpnmentare*and acoreleydesrnLed above by the proper shipping name,and ere classified.packaged, <br /> marked and Iabeledfplacarded,and era In all respects In prypercangtion her transport according to applicable Inlematlunaland natonal govemmenlai regutallorre.II export shipment and I am the Primary <br /> Exporter,I ceNry that the contents of Ws MIInment contemn to the terms of the attached EPAAckwhiedgir l of Consent. <br /> I tartly that the waste minimlzatlot statement Identified In,40 CFR 20227(a)(dl am a large quenglygeneretor)o(a)(dl em a small quantiygenerator)Is We. <br /> %wratQ:sl sage dnt Month Day Nf <br /> 16.Inlernationei Stdpments ' <br /> ❑Imponb U.S. ❑Expatirom U.S. Ponof eniryledl: <br /> Transporter signature(for capons only): - Date leaWng U.S.: <br /> 17.TramponerAck wMedgmenl ofRece'ptofMaterials <br /> Transporter 1 Printedlfy Name Signature j Month Day, Year <br /> �i•!)i)(i •Or:( l" ((4V♦ f/iUi . <br /> Transporle 2P IName S!gnalure !� ' Month Day Year <br /> 4. 1B.Olscreparwy <br /> Vis,O'saepancy,lndicatom Space ❑ Dean* El Type ❑Resktue El Patrol Refectlon ❑Fug Rejection <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPAID Number <br /> Ce <br /> raa. Fecliys Phone: <br /> 18 c.Signature oflarnata Fa ditty(or Generate) Month Dsy Year <br /> y10.Hazardous Waste Repot Management MOW Codes(le.,wdesfor hazardous waste treatment,disposal,and recycling systems) <br /> WI.1. 2. 5. 4. <br /> 1-I ) <br /> r20.Des�nat9dFaci1ftyOwrmrorOpe iator.Certification of reeelpt or hazardous materials covered by the manNestezcept2l4ad In Item tea{II ped ems SgnaNre ) _ Y <br /> DaYear <br /> EPA For 8700-22(Rev.3-05) Previous ediflons re obsolete. DESIGNATED FACILITY'S COPY <br />