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Please print or type-(Form designed for use on elite(12-pHch)typewrites) ForrnAp roved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Nam ho 2Page tot 3.Emergencysfiesponse Phma 4.1111anifestTrackingNumber <br /> WASTE MANIFEST A L .�ID b�•® 1005231744 JJ K <br /> S.Generators Name and Madmif Address! J Genend o s Site Address Indifferent than mamnq address) <br /> q2 x.3 Wovyt t-S R� <br /> ov�e)a.,>t p� I�i,S 66211 �j'Tt>oIG"1?�y3 c3at. ��'Z®S <br /> Generators Phone: <br /> 6.Tmnspoder l Company Name - U.S.EPAID Number <br /> qZR <br /> 00NAA 6AVII <br /> T.TranspoW Company Name US.EPAID Number <br /> B.Designated Facility Name and Site AddressG, ,y {.� y'�a,J U.S.EPA ID Number <br /> 11010 vi i Tli SS <br /> L*V'A C16.50`6 a <br /> Fool Phone: Y04)m k11z -414zoel <br /> go, 9b.U.S.OOT Description(maturing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> Ht4 and Packing Gmup(dany)) Na. Typo Quantity WLNol. <br /> 1 0P iL'186 WMTV P0VN Sou -t to4%ME7 S I O2 �F SSZ> P <br /> eel ))1 'aIR? 'O& <br /> CJOa° <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Inskudons and Additional Information <br /> �CA551ilM uf�a����at�2 <br /> 16. GENERATORWOFFEROWS CERTIFICATION:Ihereby dedamthat lhecadmis ofmisrnnsignmerd are Wyand accurately desudhed above by the pmpershlpping name,and are classified,packaged, <br /> marked and labeledfplacerded,and are in all respecffi in propercondition for transport according to applicable inlemallonsland national govemmentstregulallons.if exportshlpmant and I am the Pdmmy <br /> Expoder,IratfitylhatUiecontentsofthisconaigmnentm*ntothete oftheabehed EPAAduwv4edamotofOornient <br /> I certify that thewaste minimization smlamenildearded In 40 CFR 26227(e)Il l am a large quantitygenemlor)o (b)(gt am a scumquamitygenemer)Is hue. <br /> Genam slOgerorsPdnled/fyped Noma Signs Month Day Year <br /> —f O.intemationel Shipments — Z <br /> {., ❑Importto U.S. ❑ fiord U.S. Pon CrAtrylea ( <br /> 'z— Transporter slgnalum(for exports only): Data leaving U.82 <br /> Of 17.TrampoderAcknwdedgmentof Receipt of Materials <br /> 7mnspori Pdntedffyped Name Signature o Month Day Year S <br /> �Z/- GLVC�d 3 / <br /> CL <br /> � <br /> 4 Tominnoder2Printedflyped Name Sigmshue Month Day Year <br /> C <br /> r- <br /> 18.Olscrepancy <br /> 18s.Dtscreparwy Inclination Space ❑Quantity ❑Type ❑Resklue ❑Partial Re)eutior ❑FWI Rejection <br /> Manifest Reference Number, <br /> i: 18b.Alternate racWorGenshum) U.S.EPA ID Number <br /> J <br /> V <br /> LL Fadlity's Phone: <br /> w 18c.Signature orAiNmateFaatity(or Genemlor) Month Day Year <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codesfor hazardous waste treatment disposal,and mryding systems) <br /> W 1 p- 3. 4. <br /> a <br /> 20.Destgnaod Facllty rTvneror Operator Candlemas,of receipt of hazardous materials covered by thertmndealexcept as Med In Item tea <br /> Pdatedrfyped Naive - Sgnaure both - Day Year <br /> EPAForn 8700-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FAI i11TT iP®DESTINATION STATE(IF REQUIRED) <br />