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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ApmvedOMS No XWM39 <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2.Page 1 of 3.Emergarcy Response Phone 4.k1005232351 <br /> bntedTNuaber <br /> WASTE MANIFEST I 6 'r31�ijI.Y I r:,1 Y1;'1 r 5 JIJK <br /> 5.G,eneraloes Name and MailingAddrew - _ Generators Site Address(If dilterenttttan ma"address)1€-e3 <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name UX EPA ID Nr mlw <br /> 13 i t3Jt X5^1 f'e'i f�+ 1 u `" i 1 G t i 1 `iZ fz. <br /> 7 Transporter 2 Company Name s 1 { U-S.EPA ID Number <br /> 6.()esignated Faei6ty Name and Site Addraes U.S.EPA!D Nrxnbert 1� `ll <br /> Facililya Phone: til) "}' { '7'i !:A,- 0 e 4) <br /> go. 9b.U.S.DOT Description(rnduding Proper Shipping Name,Hazard Class,lD Number, 10.Containers 11.Tahal 1Z Unit <br /> HM and Packing Group(f any)) ND. T� WUVO1. 13,Waste Codes <br /> L <br /> W <br /> 2 96 jar <br /> sr <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATORWOFFEROR'5 CERTIFICATION:t hereby declare that the contents of this consfgnmenl are filly and accurately described above by the proper stripping narne,and are rlassiled,Paclraged, <br /> marked and Iabeledlplacarded,and are in al!respects in proper conditiorKar transport according to applicable inlemational and national governmental regulations.9 export stdpmatrt and I am the Primary <br /> Exporter,I certify(hat the contents of this consignment conform to the tombs of the attached EPA AcknovAedgment of Consent, <br /> I certily that the waste m5iimizatlon statement Identified at 40 CFR 262.27(x)(If I am a large quantity generatoT)or(b)(if Ia,�1a1J uantty generator is true. <br /> GeneratoeslOfferoes PdntedlTyped Name "' Signature g Alordh Day Year <br /> 6. <br /> IntlimatioRai Shipments <br /> Ll Impart to U.S. Export.from U-S. Port of anlryQlt <br /> Transporter signature liar exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Recalpt of Materiels <br /> Uj <br /> Transporter 4 PrintedlTypod Name Signature. p Yea <br /> . . <br /> ew <br /> Q Transputrter Prinfed7Typed Name 1 f Signature' I' � Y <br /> Ce <br /> r ) t { v <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Type ©Residua ❑Partial RepeC6on ❑Fal Rejeam <br /> Manifest Reference Number. <br /> 1 BE Altemate Facility(or Generator) ", oa U.S.EPA 1D Number <br /> ) <br /> LL Facilitys Phone: <br /> 18c.Signature of Allamate Facirdy(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codtrs pl.j codes for hazardous waste treatment,disposal,aril recycling systems) <br /> LU <br /> 4. <br /> 20.Designated Favilly Owner or Operator.Gerlih000n of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed(Typed Nome Signature Month Day Y <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obso!ele. <br /> TRANSPORTER'S COPY <br />