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Please pnnt or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST _ i , _ ,, U'0 6 5 8 7 9 4 7 1 11( <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address)ql� WX re .5'1n440 <br /> vv N N I� <br /> 4 <br /> Generators Phone::.,-. <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name US.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> • iia ... <br /> • <br /> If .11 <br /> .11 _ <br /> FaGllys Phone: ' `` "' <br /> ga, 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Centel am 11.Total 12,Unit <br /> HM and Packing Group(If any)) No. Type Quantity WUVOI, 13.Waste Codes <br /> C 1. <br /> O <br /> F- <br /> W <br /> c7 <br /> 3. <br /> 4. <br /> 14.Special HandlingInstructions and Additional 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 and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(it I am a small quantity generator)is We. <br /> Genemtorsl0l(erors Prin*11Typed Name Signature Month Day Year <br /> -� 16.International Shipments <br /> z El import to U.S. ❑Export from U.S. Port ofentrylezit <br /> Transporter signature fico exports only): Date leaving U.S.: <br /> w 17.TransporterAclmowledgment of Receipt of Materials <br /> OTrentedRyped nsporibf i PriName SignaWre Month Day I(� <br /> CL <br /> t I <br /> Up Transporter 2 PAntedrfyped Namei. <br /> KSignature Month Day Year <br /> r <br /> t18.Discrepancy I' <br /> 18a.Discrepancy Indication Space El Quantity ❑TYPa ❑Residue ❑ <br /> ty PaNal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL FacilRy's Phone: <br /> r18c.Signature ofA temate Facility(or Generator) Monro Day Year <br /> CDz <br /> a 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> G 1, 2.• 3, 4. <br /> 1 20.Designated Facility Owner or Operator:Certificafion of receipt of hazardous mater Is covered by the manifest except as noted in Item 18a <br /> PrintedrTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />