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�.- - Form Approved.OMB No.2050-0039 <br /> ign <br /> Please print or type.(Form desed for use on elite(12-pitch)typewriter.)) <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> ..UNIFORM HAZARDOUS 66-t-721-8739 � � �s� �� � G B F <br /> WASTE MANIFEST 1 09 1r j <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> VALU!'PACIRC tMfr 413: r" L'r LLF'I PACI3IICP,0T- ;T Sd SV'C <br /> �-+� �,q q 5"5' S <br /> . tt.r viiTDF t.-da 536srrr.Y 16 t ri ivf_L- �°� <br /> Generators Phone:, •r r,Pz -^. — U.S.EPA ID Number <br /> B.Transporter 1 Coft "'NarWe -Ai W3670-42 <br /> 7.Transporter2 Company Name U S EPQ.;D Num4ep <br /> 8�Design ted Facility Name and Site Address U.S.EPAID Number <br /> i h � oaaY� 'S Jsa�°� Gsd C <br /> Facilitys Phone: <br /> 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. e Quantity Wt-Ncl. <br /> HM ,and Packing Group(if any)) No. Typ <br /> 0 u vrj{6( a <br /> Z 2... <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling <br /> Instructions and Additional Information ^ ''qt L a <br /> 15. GENERATOR'SlOFFEROR'$CERTIFICATION:I hereby declare tha he contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placa)ded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform't6the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste miniimization statement identified in 40 CFR 262.27(a)(if Lam a large quantity generator)or(b)(#I am a small quantity generaW Is t .li <br /> GeneratoeslOfferors Printed/Typed Name <br /> Signature Month Day Year <br /> kl <br /> 16.International Shipments ❑ from U.S. Port of entry/exit <br /> F ❑Import to U.S. Export <br /> Z y Date leaving U.S.: <br /> 4 — Transporter signature(tor exports only);. . <br /> 17.Transporter Acknowledgment of Receipt of MaterialsMonth Day Year <br /> Signature <br /> L.U. <br /> Transporter 1 Printed(,�Typed Name ,t� <br /> a `1 '�1 d Y� Month. y Year <br /> o.. <br /> Signature' <br /> agcy.- r-•" a�� ��i"9 <br /> td Da ::"- <br /> f;— QITTenspofter2 Pim1edFk Name: Y <br /> F _ <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ElQuantityElType ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate FadHty(or Generator) . <br /> V <br /> LL Faclitys Phone: Month Day Year <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Z <br /> 19.Hazardous Waste f epgrt Management Method Codes(i.e.,codes for hazardous waste treatment;dispagal,and recycling systems) <br /> w. 3: 4. <br /> 1 2. <br /> 20:Desighated Fadfity Owner or©perator.Cert ficaton of receipt of hazardous materials covered by the manifest except as rtat�d fi IOem98a Month Day year <br /> Signatr m <br /> Pri,itadnypad Nan " <br /> EPA Form 8700-22(Rev. 05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERAT®F <br />