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0 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.CMB No.20SM039 <br /> UNIFORM HAZARDOUS 1.Genc2terlD Number C-���-�7SOT� 2.Pagetof 3.Emergency Response Pacne 4.Manliest Tracking Number <br /> WASTE MANIFEST I ( 1 516)-z(oj-o,-5q1005232075 JJK <br /> 5.Generators Name and NailingPdMeSS Mp GemeraloftSiteAddress(dddleeru Nan madng address) <br /> Gemembe.Pho,a: 2°cl)234`N 01 SZ . <br /> 6.Tursponer 1 Company Name V.S.EPA ID Number <br /> MOR 'ANEclUi�1TJK1C f TI 5 I C I01300f34Z8 <br /> 7.Tm r2CcmPamy Name U.S.EPA ID Number <br /> S.Dagnated Fealty Name and Site Address OYa✓ N - U.S EPA ID Number <br /> 100 I-11i <br /> LONh 13ct CPC <br /> Fecal Is Finns: 94o2- .Ah OZ$q/0701C7 <br /> ga. 9b.U.S.DOT Deaiption(Moulding Proper Shyping Name.Haran Cl ID Number, 10.Contai ers11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if MY)) No. Type Quantity wWol. <br /> 1. UN 3 11 OeC7p3)a''C FE-0ox10E C% So ;o s.Z 2 j^� <br /> O2 p P om <br /> I91 <br /> z 2. <br /> 3. <br /> 4. <br /> 14,Speoal Ka instructions and Additional Mitmation - <br /> 9 - 45sofben-IIP WN04t Aral, C'LCSs) a�59Z <br /> he-ass <br /> 15. GENERATORNOFFEROR'S CERTIFICATION:I hereby declare Mal me contents ofIms consignment are fully and acurateff described above by the proper sNpphif name,and are classified,packaged, <br /> marked and kbeJcUplawded,and are in all respKM in proper condition for"rood according to applicable imenda mel and national cimmunmental regulations.If e W slipment and 1 am the Primary <br /> Exporter,I am*that the contents of this conslgranent conform to the terns of the armed EPAAtdnoWadgmerd of Convent <br /> I unity Mal Ne waste unm"ica6a,statement idendfied In 40 CFR 26227(a)(if I am a large quantity generator)or(b)(itI am a small quantity gerrerater)is We. <br /> GMs,sfoeV0fTwMs YFed Name Signature Month Day Year- <br /> AA S. rl+&jk_(f iL z( t <br /> f 6.Intemebra w Stainers <br /> ❑import to V.S. ❑E ped from U.S. Pont of enbyle»t <br /> Transporter agwome(for e*or6 MI& Date leaNng LLS: <br /> W 17,Transporter Ackr aedpnem of Receipt of Materials <br /> T 1 Printed?yped Name S _ Signature � �J Day Year <br /> t <br /> Is7/kf L-4 46 1G'} r <br /> Go <br /> z Tffic5v,6ftw 2 PwiledifTyped Name Signature Month Day Year <br /> t <br /> } 18. ncy er . <br /> t I taa.Discrepancy IMuatim Spam ❑ Clantity ❑Type ❑Resdua ❑Partial Rejection ❑FW Rej dam <br /> -Manyesl Referenm Number, ' <br /> 18b.Altemate Facility(or Generator) - U.S.FPA ID Number <br /> J <br /> U <br /> LL Faofity's Ph": <br /> cu 18,Skjra ofAdleWta Faddy(a GenWatoo Month Day Year <br /> Q � - <br /> 2 <br /> H10.Hazardous waste Report Maropmerd Me4rm Codes(i.e.,codes far hazardous Mate treatment dspmal.and recycling systems) <br /> C 1. 2. 3. 4. <br /> x++41 <br /> 20.Dn4gra4N Faceily0merm Opera or.Ceffmtion of receiptol hamdo s materials covered by the manifest nc ed in Item 18a <br /> 1t PrinroMyped Name — Signature Month Year <br /> � <br /> 5 � F3 <br /> EPA Form 8700-22(Rev.3-05) Previous editons are obsolete. DESIIGAATEDF rTYTODESTINATIONSTATE(IFREQUIRED) <br /> 11369.2111 <br />