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x 1 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generaior ID Number 2.Page 1 of C e§ nse Phone 4.Nlanitest Tracking Number p <br /> WASTE MANIFEST `. s: G D F <br /> III - ►, . •, . <br /> 5.Generator Name and Mailing Address Genetatofs tel ddresS,(OdifferentthanMailing address) <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name 4T7y �' T�� �, U.S.ESA m Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity vyt.fvol. 13.Waste Codes <br /> �O <br /> z 2. <br /> W <br /> i <br /> 3. <br /> i <br /> 4. <br /> 14.Special Handling Instru;aionsandAddltional Information <br /> 15, GENERATOR'SIOFFEROR'S 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 a-id labeled/placarded,and are in all respects in proper condition for transportaocording to applicable internaticnai and national governmental regulations.If export shipmen:and I am the Primary <br /> Exporter,I certify that the contenls of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I cediythat the waste minimization statement identif ad in 40 CFR 232.27(x)(f I am large quantity generator)or(b)(if t am a snail cluantty generator)is true. <br /> Generator's10Beroes PrintedrTyped Name Signature Month Day Year <br /> J 16.International Shipments <br /> I.— ❑Import to U.S. ❑Export from U.S. Port of entrytexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> UM 17.Transporter Adowledgrent of Re 3eipt of Materials <br /> �2 Transporter 1 Printed/Typed Name Signature Month Day Year. <br /> O <br /> QTransporter 2 Prntedrryped Name '` Signature Month Day Year <br /> a <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity []Type ❑Residue ❑P.dial Rejecion ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> .< Facilkys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Wionth Day I Year <br /> " 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous vraste treatment,disposal,and recycling systems! <br /> 1. 2. 3. <br /> Notice:New federal form. State of <br /> 20.Designabc Facility Uvneror Operator:Certification of receiotof hazardous materials covered by the manifest except as noted in Item 18, California requires generator to photocopy <br /> PrintedfrypedName Signature and mail to IDTSC within 30 days: <br /> A.O. Rna 460. Sacrttnento CA <br /> EPA Fo rn 8700-22(Rev.3-05) Previous editions are obsolete. <br /> G-ENZEF,ATC R--"S o',l1 FIAL CC-RY <br /> 6'd £966-8Lti-60Z eaiaAIiS no-1 e99:6 1 60 9 6 pea <br />