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Please print or type.(Fort designed for use on elite(12-pitch)typewriter.) Form <br /> Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS i Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Ma ife9T cking Number <br /> WASTE MANIFEST a fjv....';z...,t In "� ( 1 I V <br /> A i. ..- ':Z {J{JK <br /> 5.Generator's Name aM Mailing.scuress Generators Silo Address pix different Man mailing address) <br /> Generators Phare: �( r "Uh <br /> 6.Transporter 1 Company Name LLS.EPA ID Number <br /> i . "kif 'iAc Z <br /> 7.Transporter 2 Carrpany Name U.S.EPA ID Number <br /> 8.Designated Fadhry Name and StteAddrees U.S.EPA ID Number <br /> 1i� :Cr.Ji�tii GNJs1T <br /> i1Z. t o[ 5.:r, <br /> IWY 95 f II Ki '>' :r4' F.F,A'FPYI r BEA'M'S', NV S'i <br /> Fadi sPhone: ;:frit- . ih :Ort'.. <br /> gy, 9b-US.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.unit - <br /> HM and Pecking Grwp(ill ani 13.Waste Codes <br /> No. Type Quantity WLNd. <br /> y, 1.N,.�-P.C'PA HAY.APJJi1l7J MA 4'f C, v. ': <br /> ¢p n_;Zi ANL A&Sr;RA631'fa i ` 1,r <br /> ZZ Iti P.CPA HAY.AIIUvIre 101 1 <br /> 0 IsJABABvIAD ?iIb} <br /> a.f <br /> (11FAC EE. HA2ARnO(is WAS1'6. —y \ <br /> i R1i 1CTfiL• [•:t (r':'a N9'Ft;'. _-.� .r ` �• i ,j —_ <br /> i.NJN-.RCAA itAEAPf <br /> 14.Special Handling Inshulions and Additional Information <br /> .'7Ot r- it)."5rr 1,10131t,?lf- f f4_F. <br /> :-'AF.U' i'i: tCr I; t1`%tr* •r7-, hP •ii}w, <br /> A3 TIFG1^.'3'.RANP fC•OWMAll"T # '5 It-;TV <br /> 15. GENERATOR'S/OFFEROWW 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 IabeledlpFacaNed,and are in all respects in proper condition for transport according to applicable intemalional and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I tartly mal:he contents of this consignment conform W the terms of the attached EPA Acknowiedgment of Consent. <br /> I certify tied the waste minimization statement idenefiellm 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> GeneatorstORemes PmteMyped Nemo Signature Month Day Year <br /> rl <br /> � 16.IMematicnal Shiprtrmts <br /> F El import to U.S. ❑Export from LLS. Pod ofDate;e ving U.S. <br /> — Transporta signature(tor exporh only). Dale leaving U.S.: <br /> w <br /> 17.TransporterAtlu Mw gment of Receipl of Materials <br /> OTansporler 11 Printed/Typetl Name `� C Signature � - f Month Day Year <br /> zQ I ranspater 2 Printed4yped Name Signature r M nth Day Year <br /> C <br /> r <br /> 18.Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑ Ouanfi I F-1 Fall Reaction <br /> ry El Tit ❑Residue Partial Reaction <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(a Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 1 .Signature of Allemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> y <br /> 19.Hazardous Waste Report Management Method Codes tis,codes for hazardous waste treatment,disposal.and recycling systems) <br /> p 1 2. 3, 4. <br /> 1 20.Designated Facility Ovmer or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Ponted(Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />