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Please prod or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS ,,' r_ � Emergency pone Phone 0.Manifest rip umber <br /> 1.Generetar ID Number 2. t o/ 3.Erne a Res <br /> WASTE MANIFEST ' ' 1 ' 0 '41 4582765' JJ K <br /> 5.Ceneletar's Name and Mairtg rens neraWfs SiteAlmese In different than maskg address) <br /> r.. <br /> Fd I•: n:Cflpll 7E i,d I FOb.. iitrl _".9 r r i-j._rt`•. - <br /> /-'IY:?37�eL'-r', <br /> CeneraWr't Phone: `i <br /> 8. renspatari nay nre U.S,SPAID Number <br /> E:w;rbrtl'iiCr,{.�.1 LOCIISLrS 'I",r .1 i" <br /> 7,Transit 2 Company Name . .EPA I NaN>ar <br /> 8.fLasl rented FpclliyName and SeePddress U.S.EPA ID Number <br /> -.rt. <br /> Faetilys Phare: - <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Now,Hamed Gass,ID Number, 10.Comainre 11.TOW 12.Unit 13.Waste Cadet <br /> HM atm Pecking Group(Iany)) No. Type Ouentiy MNot <br /> { <br /> Z 2. <br /> w <br /> C7 <br /> 3. <br /> RFCL- <br /> JAN 2 9 201E <br /> d. <br /> ENVIRONMENTAL HLALl H <br /> 14 Special Handling lnstruceons and Additional information aE'_5.i7: <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ere fully and accumtaly described above by the proper shipping name,and ares classified,packaged, <br /> marked and Iabead/Nacarded,and ere m all respects in proper condition for"report according to applicable Intematlonaland national governmental regulations.d export shipment and I am the Primary - <br /> Exporter,I certify that the contents ofthle mnsigiiimuenttonfomstu.iba.lgrms of the attached EPAAcknowiedgment of Ganem, <br /> I certify that the waste minimization statement idsntlfied in 40 CFR 282. (a)(d I sen a lenge wanfity generator)or(b)(di am a small quantity generator)is true. <br /> GenereWysiOrtemes PrintedlTyped Name Signature Month r <br /> C'Uf <br /> i <br /> -li 18.International Shipments <br /> F ❑import W U.S. ❑Expalher,U.S. Part ofemry7exk <br /> = Transporter signature(for exports ordy): Date leaving U.S.: <br /> X 17.TresporterPcknoMedgment of ReceptofMatedals I <br /> Tragsponr 1 Prinledrryped Name Signature.' '� Day Year <br /> y 7 <br /> ranpoder 2 Plintedayped Name Signawn, r Mach Day Year <br /> oc <br /> 18.Discrepancy <br /> 18a.Discrepancy Indlcallon Space ❑Residue <br /> ❑ Quandt' ❑Type Partial Re)ectlon ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b,Amar Facildy(or Generator) U.S.EPA ID Number <br /> V <br /> LL Fecllly's Phone: <br /> r.9 <br /> 18c.Sitinature ofAftemate Facility(aGenerator) Month Day Year <br /> C <br /> 19.Hazardous Waste Report Management Method Cod%(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. / '/ I 2. 3. 4. <br /> 20.Designated Facility Ovmear Oparetor.Certification of receipt of hazardous materiels covered by the manifest except as noted In Item 18a <br /> Printrall'Tpedmer SignatureMonth Day Year <br /> ( 42 1/D <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. • DESIGNATED FACILITYtO GENERATOR <br />