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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Fon Appiroved.OMB No.2D%W39 <br /> 2.Page 1 3.Emergency Response Phone 4.ILV&dlfadd N ber <br /> I-C%eneralor ID Number <br /> UNIFORM HAZARDOUS 1 "52351 JJK <br /> WASTE MANIFEST 10] 0052 <br /> 5.Generators Name and MailinglAd4ress Generatofs Sig Address(rdirrierwithan nag address) <br /> lot 1; <br /> 17,S411 <br /> Generators Phone:-4 1 <br /> 6.Transporter 1 Company Name U.S.R 0 RWTW <br /> 0. 3i)(j I <br /> 7.Transporter 2 company Name U.S.EPA ID Number <br /> B.Dasigratad Fadity Name and Site AddressW <br /> U.S.EPA ID Nua <br /> --3 <br /> FacVY's Phone: �';uy UvAi- iy-PtA O�k /-AF7 078 1104pill <br /> S, 9b.U.S,DOT Description(including Proper Slinipping Name,Hazard Class,ID Number, 10"Containers %Total 12.unit 13.Waste Codes <br /> HN and PaWng Group(if any)) NO. Type Qum WLfv,,. <br /> 1. q0 <br /> in <br /> t. <br /> Lu va <br /> 3. <br /> 4. <br /> SIP 02 20}� <br /> L <br /> %S I Handling instructions and Additional Information <br /> UKV-i 111i, ( ENVIRONMENTA <br /> P"t C, ix.,j CIO N-.q-i- <br /> 15. GENERATORWOFFEROR'S CERTIFICATION;I hereby declare that the Contents of this consignment are fully and accurately described above by the proper shipphq name,and are clawhiled,pacitaged, <br /> marked and lateled1plararderl,and are in all respects in proper oDriddionTar transport according to appllicaNe intemafional and national governmental MulatiDnis.if export shipmentand I am ft Prinary <br /> Exporter,I certify that the contents of this oon6ignment oonform to the tarns of the attached EPAAdmowleodgiment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262,27(a)(I I am a large quantity generator)or(b)(if I a%a=4 <br /> fl�rantrtygar� <br /> Jis true. <br /> Goronallors/Offernes PrinteclTryped Name Si nalure MMWI Day Year <br /> %Intmationd'Shipmants1� <br /> ❑import to U.S. ❑Export from U.S. or en <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> LU 1T.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PriniedrTypad Name Signature MD* Day Year <br /> I cr] <br /> Transporter 2 1`4ntedfrypad NameMonthDay Year <br /> Slgna�uro <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SW Qw." El Type Residue ❑Partial Rejection Elul Rejection <br /> Manifest Reference Number-. <br /> 1Bb.Alternate Fadlay(or Generator) U.S.EPA ID Number <br /> LL FadliVs Phone: <br /> Uj 18c.Signature ofAterrate Facility(or Generator) Month Day Year <br /> 0 <br /> T, 19.Hazardous Waste Report Management Method Codes(i.e..oodes for hazardous waste breatmeK disposal,arijrocycling systems) <br /> LLI 1 2. 3. 4. <br /> 20.Designated Foorgy Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> Printod[rypod Nome Signature monm Day Yea <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY <br />