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Please print or type.(Form designed for use on elite(1201ch)typewriter) Fpm <br /> Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Numoer 2,Page 1 of 3.Emergency Response PMre a.Mandest Tracking Number <br /> WASTE MANIFEST . . .. . r. '' , i- 1005486694 JJ K <br /> 5 General Name and Mining Address General Site Address(if different Men mi address) <br /> Generators Prone'. <br /> 'ramsparar 1 Company Na..^e U.S.EPA ID Number <br /> 7.Transpo 2 Company Name U.S.EPA ID Numoer <br /> 8.Desgnaled Faddy Name art Ste Aoaess U.S EPA ID Number <br /> .ir.e N <br /> NNYtbN-ill C- Yell <br /> 1`141 11 Phoris 'Yr a+-' - <br /> 9b.U.S.DOT 11.Torol 12 Uns <br /> ga Droiplon(rp4sdrp PrgwShigkrg Name.Hazard Class.ID Number. 1C Co�'a�ners <br /> ant Packma Group if any)) 13.Waste Codes <br /> Hh' Vc Type ouanb'.Y Wt Nc' <br /> pr :R'... <br /> O <br /> Q <br /> [C <br /> i <br /> w <br /> O _ <br /> a <br /> I <br /> td.Speaal Handing Instructions and Additional InfenmCun <br /> 15 GENERATOR'SN)FFEROR'S CERTIFICATION: I Nerdy declare Mat the contents of this consgnmed are fully and eccuakry described above by the bmier shipping name,arc are classified.packal <br /> marked and tabeledrpiacardedand are in all respects in proper condition for transport aabording to applicable intemational and national governmental regulalims,d export shipment and I am me Primary <br /> Exporter I ceNiy met Me Mnknts of me cprsgnment conform in the terms of me abacnea EPA AcknaMedgment of Cc nwt. <br /> I artrty mat me waste minimimaon statement identified in 40 CFR 262 27(a)(if I am a law quantity generator)or(b)(e1 am a small quantity generator)is true <br /> - <br /> (; erato?srOfierces PnmtedTyped Name Sgnatore Monro Day Year <br /> J i6.Internal Shipments <br /> p_ ❑Import fu us El E.Port horn U.S. Pat of entryanut <br /> Transporter sgnature(for expels dray)'. Data leaving U.S.: <br /> w 1I.Transposer Adnwdedgment of Receipt of Materials <br /> Trnsposer 1 Prated Typed Nam Sgrial Month Day Year <br /> O <br /> of <br /> N <br /> Za Transporter 2 Printed! Name SgnaNre MontDay Year <br /> K <br /> H <br /> 1 18 Discrepancy <br /> 1 ria Discrepancy Irtditomb,Space ❑ Quantify ❑Type ❑Residue ❑Paruel Rejecroon ❑Full Rejection <br /> Manifest Reference Number: <br /> 1 Ed Aftemate Facility for Gereratoq US EPA fD Number <br /> J <br /> U <br /> LL Fac9rtys Phare' <br /> Ow 18c.SgMrtore of Ahemare Facility for Generator) Mont) Day Year <br /> a <br /> z <br /> V5 <br /> N ta r5.Hai Waste Repos Management Method Codes(i e. codes for hazardous waste treatment,disposal,and recycling systems! <br /> W t 2 3 6 <br /> D <br /> 1 2C Designated Facility Omer or Operand'Cerblicabon o1 receipt of hazardous matenais covered by me manifest except as noted in Item 18a <br /> Pnnted.Typed Name Signature Mont, Day <br /> EPA Form 8700-22(Rev 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />