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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackm Ntumb_er <br /> WASTE MANIFEST (>jft0184W2 1 1-A$$•1&S-7225 006 3 C, `913 , FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(d different than mailing address) <br /> mtte•(.%Pt N m male, $1c. <br /> I15 3. OUM ANO. <br /> Ltd, CSA W40 <br /> Generator's Phone:2W370-I WO <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ;�rt`v.-nr,-;B,d 0t[if►icA 71anq)cf1 kX. (W) tARKW7 5A0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> t _ <br /> B.Designated Facility Name and Site Address " U.S.EPA ID Number <br /> Adm Chart irA T,WmW <br /> Aft 671 07 NAAEJQQZ2D8E12I <br /> Facilitys Phone: 5"O-J229 <br /> " 29 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM <br /> and Packing Group(if any)) No. Type Quantity Wt./Vol. t3.Waste Codes <br /> t(Q,UN 1993, "61 a 1' Mil lat►ic NtjUWS,ILQti, <br /> o (ACES t'QNE rOLUENB).3.PGR MINI) <br /> z 2. <br /> w <br /> 3. <br /> Rim <br /> 4. <br /> MAY <br /> 14.Special Handling Instructions and Additional Information %Vj1@0NyW <br /> P1Cljkd Rill497WUocutlwlt N:rr,61!0 TMD �.� <br /> I)EF,KM28; AlrMfil LIP,L( <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,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 EPAAcknoWedgment 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'sl0fferoes Prnted/Typed Name bignature PETE Day Year <br /> —i 16.International Shipments f <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature for exports only): Date leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Prinled/Typed Name.. Signature n' ont ay Year <br /> a0 j i ! �!'� I I f <br /> Z0) <br /> Transporter 2 PrintedlTyped Name Signature Month Daly Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 1 Bb.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Zi <br /> U <br /> Q <br /> Facility's Phone: <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> �r <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />