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Please print or type.(Form designed for use on elite(12-pitch)typewnter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Wfleradox ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST L?J(��`��'.�// f _ 14M424-83DD.. 1001827316 JJ K <br /> 5.Generators Name and Mailing Address c i ^ /�, _!L Generators Site Address(it different than mailing address) <br /> 77 <br /> !fi/ice/Av//�3 <br /> U.T sporter 1 Com Norge U.S.EPA ID Number <br /> plMnental Services CG DSM13M <br /> 7.Transporter Company Name � ��,� r U.S.EPA ID Number <br /> /f/0 //�'lJ .mss !!r y!n C CARIM1177W: <br /> 8.Designated Facility Name and bud Addmss21�A. ',EM(,: U.S.EPA ID Number <br /> 2= 4r M)andv Mive East <br /> Fe"ey, N1/8941IM <br /> FacWkys Phone: 7754764Mr, <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contairrers 11.Total 12 Unit HM and Packing Gmup((K any)) No. Type Quantity WtNol. 13.'Nasfe Codes <br /> Ise <br /> = 2 <br /> W <br /> c7 <br /> 3. <br /> 4. <br /> 14.Speaal Handling Ins ens and Additional Info"allon <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents M this consignment are Nlty and accurately described above by the proper shipping name,and are dassilled,packaged, <br /> marked and labelednplacarded,and are In all respects in proper condition for transport according to applicable intemallonaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknewledgmeht of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(ti I am a large quantity generator)or(b)(dl am a small quantity generator)Is true. <br /> Genemlaes/OBerors rinled/Typetl Name Sign re Month Day Year <br /> 17 1231&2 <br /> —s 16.International Shipments <br /> ❑Importto U.S. ❑Export the.U.S. Pod of entry/exit <br /> Transporter signature(for exports only): Date salving U.S.: <br /> W 17.TransporerAclanvoldgmerd of Receipt M Materials <br /> OTrenspoder1 P' ypad Signature Month Day Yas <br /> a <br /> QTrans r2 Printedlrypetl Name 'nature Month Day Yee <br /> C <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceEl 1 <br /> Quantity L]Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.vitamers Facility(or Generator) Manifest <br /> EPA ID Number <br /> U <br /> Facililys Phone: <br /> W 1Be.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Repent Management Method Codes(i.e.,codes for hazamous waste treatment,disposal,and recycling systems) <br /> W 1 2. 3. 4. <br /> 20.Desigwted Fadiity Owner or Operator.Certificason of receipt of hazardous materials covered by the mandest except as noted in Item Ise <br /> Pdmtewlyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />