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Please print or type.(Form d(signed for use on elite(12-pitch)typewriter.) <br /> UNIFORMHAZARDOU 1 Generator ID Number Form Approved.OMB No.2050-0039 <br /> WASTE MANIFEST 2.Page 1 of 3.Emergency Response Phone <br /> 4.Manifest Tracking Number <br /> 5.Generators Name and M fling Address j^ <br /> " 1', rJit <br /> GenereCo s Via (if different than mailing address) ._ G B F <br /> A10"MIN,Wit I c:<attp <br /> .'moi%::;i.t��tlift:#tw,i'y Itis;a ttt� <br /> Generator's Phone: 1`� s,i,F• ` ?rr <br /> 6.Transporter 1 Comp--ry N me ' <br /> _ U.S.EPA ID Number <br /> 7.Transporter 2 Company N me G <br /> r, <br /> U.S.EPA ID Number' <br /> 8.Designated Facility Name nd Site Ad fess <br /> U.S.EPA ID Number"" <br /> �t�i1�:;+VW�:L.t ti'I'FtF.t=1 i <br /> Facility's Phone: <br /> ga. 9b.U.S.'DOT Descn ion(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Pecking Group(i any)) 10.Containers 11.Total 12.Unit <br /> 1. No. Type Quantity Wi.Ncl. 13.Waste Codes <br /> o <br /> w <br /> Z 2. <br /> UJ <br /> 3Z1("tb ?i tib <br /> 3. <br /> , <br /> 14.Special Handling Instruction and Additonal Information I <br /> .14uo# %VA##-ii W <br /> , 1.441.'; <br /> 15. GENERATOR'SIOFFERO 'S CERTIFICATION: I hereby declare that the cwrlents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placar ed,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 ntents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minii iization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)lift am a small quantity generator)is We. <br /> Generator'slOfferor's Pdnted/Typd Name <br /> Signature <br /> Month Day Year <br /> -1 16.'Intemat anal Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/ex t <br /> Transporter signature(for exports only): _ <br /> W 17.Transpoder Acknowledgment¢f Receipt of Materials Date leaving U.S.: <br /> W Transporter Pdnled/Typed Nam <br /> Signature n <br /> rl 1 ,' ;: Month Day Year <br /> Z Transporter 2 Printedffyped Nam <br /> � Signaturb - �" - -- -�, • <br /> Month bay Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spa <br /> ❑ Quantity ❑Type ❑Residua <br /> ❑Penial Rejection `❑Full Rejection <br /> 18b.Alternale Facility(or Generat r) Manifest Reference Number: <br /> Zi <br /> L) <br /> 1;rti <br /> LL Facility's Phone: <br /> W 18c.Signature ofAtemate Facility or Generator) <br /> Q ONMENTAL m Day Year <br /> Z HEALT <br /> 19.Hazardous Waste RepOrl Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> W <br /> D 1' 2 3. <br /> Notice:State of California requires <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 182 gernerator to photocopy and mail to <br /> Printed/Typed Name Signature DISC With 30 days: <br /> P.O Box 400 <br /> EPA Farm 8700-22(Rev.3-OS) Pre ious editions are obsolete. Sacramento,Ca 95812-0400 <br /> —GENERATOR'S 1Nrriei rnnv — <br />