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� I <br />Please print or type. (Form designed for use on elite (12 -pitch) typo riler.) Form Approved, OMB No. 2050-0039 <br />UNIFORM HAZARDOUS I' . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Maniftcking Number <br />WASTE MANIFEST 004540672 JJ K <br />5. Generators Name and Mailing Address G2Yi a bPs i re S ICA 1 tfah mailing address) <br />ff40, I4T(,;N 140M) <br />F1C13fy 'i.tCIMH'.:1P1T <br />WA Y "A 6tt3 >b2 <br />Generators Phone;,, <br />6, Transporter 1 C n U.S. EPA ID Number <br />i-,;1 ��r.,P� c,s ^F'. c. ^':r .. �iF <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />i <br />8. Designated Facility Name and Site Address <br />&. VE,FtGRF F:N <br />e480 cAfflTFi AV <br />NEWARK. (`A. ` 4?ft(? <br />Facility's Phone: ' -qj-�j l <br />9a 9b. U.S. DOT Description (including Proper Shipping Name, H zard Class, ID Number, <br />HM and Packing Group (if any)) <br />1. <br />lVaxi RC'RA K axardousa ONasi.u. LKTA i 0.1 i-'. 'vL ; i kt� t € i• .i. , t <br />z 2. <br />w <br />4. <br />U.S. EPA ID <br />(.;A lls06tP,`i�''.i•i6fD <br />10. Containers 11. Total 12. Unit 13. Waste Codes <br />No. Type Quantity Wt.Nol. <br />14, Special Handling Instructions and Additional Information <br />st±' <br />1- tAF'#d)6..ERS TO E';f'.. 40 fit lf5 l biAIP'1't-, l.. 113'td. <br />Wf;AR Pf"[: <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby decla <br />a that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />international and national governmental regulations. If export shipment and I am the Primary <br />marked and labeled/placarded, and are in all respects in proper <br />ondition for transport according to applicable <br />confor <br />Exporter. I certify that the contents of this consignment m t <br />the terms of the attached EPA Acknowledgment of Consent. <br />262.27(a) I a large or (b) (if I am a small quantity generato) is true./'% <br />I certify that the waste minimization statement identified in 40 CFR <br />(if am quantity generator) <br />Month Day Year <br />GeneratoesrOfferoes Printedrryped Name <br />Signature r <br />J 16. International Sh n s' El Export from U.S. Port of entry/exit: <br />j--- Import to U.S. <br />Z Transporter signature (for exports only): Date leaving U.S.: <br />IX 17. Transporter Acknowledgment of Receipt of Materials Y88r+ <br />Month ay " <br />a <br />Transporter 1 Printedrryped Name Signature a <br />p <br />Z 2,04 f '. <br />z Pnnted[T ed a e Signatur Month Day Y <br />Transporter 2 YP <br />F <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />I <br />uQ <br />Facility's Phone: <br />Month Day Year <br />w <br />18c. Signature of Altemate Facility (or Generator) <br />Q <br />z <br />19. Hazardous Waste Management Method Codes (i.e., code for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />%Report <br />1 / 2. 3. 4 <br />20. Designated Facility Owner or Operator: Certification of receipt of azardous materials covered by the manifest except as noted in Item 18a <br />Mgmth qay Fear <br />Prirtt�c7lTyped Name ` Signature <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. TRANSPORTER'S COPY <br />