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Please print or type.(Form designed for use on elite(12-r vpewrlt .) rorm nppruveu.vmD Mi.LV�VQ; <br /> UNIFORM HAZARDOUS <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response F ro, <br /> Manifest Tracking Number <br /> �y <br /> WASTE MANIFEST I;;A!_1T'D013:Jf 1 :$`& -1t ar7 r2 0 :i�+( �'FFi��<O u FLE <br /> 5.Generator s Name and Mating Address Generators site Address(d dflierent than mailing address) <br /> 1(�tk.f�",frLXilt'h�ft=fs'4f �,;�T1T14�' <br /> �4ot*tvi. f idJ2 <br /> Generator's Phone:20%4o-?-.%:,4 <br /> 6..Transporter 1 Comparry Name T� 6, U.S.EPA ID Number i, <br /> :1 +`'kW-,r-8d f#'s Ct]I [t:E� 1rK 1��ry ? I..Jc7'- Jit; <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> t.z FL,Acp iw <br /> PO J,r 8.� 95.1 t u fat kl.t_ 1d1rT,;it 3 tt t <br /> 54wa I W awl N <br /> Faality's Phon [ -4241-21 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WINd. <br /> LWU <br /> 3. ..� <br /> 4- <br /> 14.Special Handling Instructions and Additional Informaliq <br /> i�41-42KA rAVVV64 'i IbC�' CXf_'.t n7� 12 rJIV4:i <br /> 15. GENERA70R'SfOFFEROR'8CERTIFICATION re are that the contents of this consignment are fully and accurately descr bed above by tt a proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,crnd are in all respects in proper Gond tion for transpod accord ng to applipble international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,l certify that the contents d this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if 1 am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratoeslOffemr's Printedrryped Name igna on Day Year <br /> Aq i <br /> _r 116.International Shipments <br /> [I Import to U.S. ❑Export from U.S. Port of enbylexit <br /> Z <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Regeipt of Materials r <br /> h Day Year <br /> W T Printedffyped Name I gna Q <br /> a <br /> ff � � <br /> Z Transpoder2 PrintWTyped Name Signature <br /> Month I ay I ear <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> ,4 <br /> Man'destRe RoNumber. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL <br /> Facility's Phone <br /> LO 18c.SignatureofAllemateFklity(orGenerator) Month Day Year <br /> a <br /> Z <br /> y 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. f '. <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedfrypedName Signature—? Month Day Year <br /> r. <br /> EPA Form 8700-22(Rev.3-05) Fkious editions are obsolefe. TRA'NSPORTEWS COP <br />