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Please print pe:(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> FORM HAZARDOUS 1.Generator ID Number 2.Page t of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST '? r r <'� St �E ! 1 7. - 01 2 G B F <br /> 5.Generator's Name and Mailing Address Generator's Sire Address(if different than mailing address) <br /> tA-Y,'°° <br /> r VJ C4 i <br /> Generator's Phonero d �+ 6 f -``1 <br /> 6.Transporter 1 Company Name ° U.S.EPA.ID Number <br /> a s <br /> tB.Y i 1.e d "7 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> \Z 3 � i°1P Z q 4� t-z tc- b i t. <br /> FaRty Urr?. p° N .:+ "' <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> OC 1 ��� �$:.��- Gt�i�'i-y,,,l����4D� Fv�'�a'�+ 6°D 4{`t3 1•� � a� <br /> 0 4, <br /> W 2. <br /> Z <br /> UJ <br /> R7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> w7=r'� fro f.6at$� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby deciare 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 terms 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)(if I am a small quantity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name Signature p Month Day Year <br /> J 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U. Port of entry/exit: <br /> Transporter signature(for exports only): vvvvvv Date leaving U.S.: <br /> 1Z 17.TransporterAcknowWgment'of Receipt of Materials <br /> Transporter 1 PrintelfTyped Name Sgna&xe Month Day Year <br /> O _.._ <br /> Transporter 2 Printed/Typed Name Signature Month Day Year-` <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> W <br /> ta+. FacllitysPhone: Month Day Year <br /> j 18c.SignatureofAltemate Facility(or Generator) <br /> Q " <br /> z <br /> 19.Hazardous Waste Report Management Method CodesQ.e.,codes for hazardous.waste treatment,.disposal,and fecycling systems) <br /> ILIA 1, j 2. .• 13. - 4. <br /> 20.Designate Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedlryped f <br /> 7Sigr afire / Month Day Year <br /> i � f <br /> r� <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br />