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<br /> Form Approved OMB.No 2050}0039(Expires9 30-99I ee.lnsfruc#ions on back Af a e 6,
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<br /> `J I.' Generator's US EPA ID No. Manifest Document No. 2. Pagel Information in the shaded areas.
<br /> UNIFORIYI: HAZARDOUS fs riot required by Federal law.
<br /> WASTE MANIFEST r . t`' E °y � � 4.. $. 4 21 of 'I
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<br /> gg ~ 7. Transporter 2 Company Name 8. US EPA ID Number -`E State TranspdrteY }D fResaryed
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<br /> 0 V 9 Designated Facility Name and Site Address 10. US EPA ID Number Stale Faultty s IDS z
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<br /> IcQ 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number 12..Containers 1.3. Total 14 Unit
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<br /> u0 15. Special Handling Instructions and Additional Information 24 HOUR EMERGENCY (800)4718
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<br /> Q16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed,
<br /> V marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations.
<br /> If I am a large quantiy generator,1 certify that]have a programin place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically
<br /> s�.V) practicable and that I Gave selected the practitable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health
<br /> and the environment,OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is
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<br /> available to me and that I can afford.
<br /> nntte /Typed Naame p r Sign%tur / j Mo�rtE a Yx
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<br /> 3 T 17. Traps orter 1 Acknowleclement of Receipt of Materials'
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<br /> 18. Trans orter 2 Acknowled emenl of Recei t of Materials
<br /> 0 R Printed/Typed ed Name g Monih Day Year
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<br /> U F 19. Discrepancy Indication Space
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<br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest exce t as noted in Item 19.
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<br /> DO NOT WRITE BELOW.THIS LINE.
<br /> DTS.0 8022A (1/99)
<br /> EPA 8700-22 Yellow: GENERATOR RETAINS
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