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Please print or type.(Form designed for use on elHe 12 itch)typewrite[) Form Approved.OMB No.2050-00339 <br /> UNIFORM HAZARDOUS 1.Generator ID"bar 2.Pape 1 of 3.Emergency Response Ptmne 4 MarifectTraekkg Number <br /> WASTE MANIFESTFLE <br /> 5.Generators Name and mumg mala JeAensi Sms Redress(a abfereni man marling address <br /> GanNsbraPMrw?.'. i3f: +Y=i7; <br /> Comm Nerre U.S.EPA Number <br /> 7.Transponer2 Company Name U.S.EPA ID Number t <br /> .Deogmtad Facility Name and Sea Accum <br /> U.S.EPA ID Number <br /> ga, tib.U.S.DOT Descdption(induding Proper Shipping Name,Hazard Class,10 Number, 10.Containers <br /> HM and Patlong GmuP It any) No. Type Qumtily WtNol, 13.YfaataOadn <br /> z t-'r•2��!- _ -s- iisx.rna,7�.$ Fu.w. :,.xu st_.=s:�;i t,t <br /> 1.'FrfYVj .�Sm =— ..IGI <br /> !CYr 1 <br /> 3"_?.'.).. ..s;JS i-l}�talti'3�cta.T1 (3s:t1ClUags j73JY¢..p1+:.>�?but.::•SiC1Fsi.r.. <br /> a.tfs>-v "r+Il <br /> 4. <br /> 14.SPedal H"Hng ftWuctom and Addifioml iraormatian Cit PdJi7l[t.1. - <br /> "� t.i:•T�T.r�L, `.,..I,L} �.: -'... • �, f. -} iT1 �i!J. . 4f�.. <br /> 15. GENERATORWOFFEROR'S CERTIFICATION: I herebydedare that bre contents of this consignment are fully and accurately described above by the proper shipping name,and are classified.pacuaged, <br /> marked end labeledlplamrded,and aro in all respacds in proper cmmiGon for transport accordng to applicable international and national governmental regulations.If export shipment and l am the Primary <br /> Exporter,I certify that Ne contents of this mmgnment conform w the terms of the attached EPA Acknwdedgment of Consent,. <br /> I certify that the wasle minimization statement Identified in 40 CFR 26227(a)(if I am a large quanaty generator)or(b)(d I am a small quanby,generamr)a We. <br /> Generators) rots Primbouryped Name Signature Month Day Year <br /> p 16.International Shipments <br /> z ❑Import t U.S. ❑Export bwn U.S. Portaf entrylexii: <br /> Transporter signature for exports only): 0•dte leaving U.S.: <br /> W 17.7ranspormrAdvlowledgment of Receipt of Mearals <br /> Transporter 1 Prime yped Nameof <br /> igmWre m ag <br /> a <br /> I I f f - <br /> TransporW21prinoodflyped Name Signature Month Usy Year <br /> F <br /> 18.Discrepancy <br /> 18a.Diacrepanty Indaation Space ❑ Quamiry ❑Type ❑Rescue ❑Peter Rejection ❑Ful Rejecton <br /> r <br /> i <br /> Manifest Reference Number. ) <br /> n Bb.A4emate Fadliny(or Generator) ILL EPAM Number <br /> REQEIVE <br /> U <br /> LL Fadl'le <br /> Phone: <br /> 0 18c.Signature utAlkm im Facility(a Gmaramr) <br /> Momh DaY Year <br /> 2 <br /> h19.Hezenlouie 9sle Raport Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and mayom9 systems) <br /> G 1. 2. 3. 4. <br /> I ENVIRON EN <br /> 20.Desigraled Facdty Owner or Operator.Cartificacon of receipt of hazardous materials covered by the memteat except as noted in teem 18a <br /> Ionmeri Name Signature Month Day Year <br /> I i <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br />