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0: /15/2013 14:20 20952°` 'i 6 BCI z:"TT WAREHOUSF PAGE 12x'13 <br /> nyn <br /> Pieria print or tops:(Form designed:fot'men elite(124itch)typewmer.) -Form Approved.QMB No.2060=0039 <br /> UNIFORM HAZARDOUS t„t Yic Slur ID NculSlfer -Pfi t i 8.Ernangenay Respor a F.nprte 4.MsnifegtTracking Number . <br /> WASTE MANIFEST ✓ �� $ Ia � JJ ft <br /> 5.Generator's Name and Mailing AdtkeSs } Rff San jfor Site Address f0 dfflwennt than mairiq addre s) r J/ <br /> ' - ,fa,��`��1 r/¢�',y✓ r” "-.f,7'+�'Y�-�{T F�` �i dy'�fi jl�fw-�/�' gh��+'���Y�����r�/ { !�/�f f� , <br /> Generator's Phone:' .e `7^'5` <br /> d;Transporter I.Company Name U.S.ESA ID N "ECEIVED <br /> 7.Transporter 2 Cnmoany N'sme U.S.EPA ID Number <br /> _t3.DesignateU U.3_EPAID Numher_ <br /> 63adSin Ith Ago. <br /> ewark,Qa.S4W cAaw* 1RONMENT L <br /> FacBily s Phone: <br /> s# -1 H EALT'H DEPARTMEN <br /> ga 9b.U.S.DOT Description(indutl'hV Proper ShlpDing Name;Hazard Class,ID Numbs, 41)-Container: 11.Trial 12.Una 13.Waste Codes <br /> HM andd�Pac:king Grouppr(if aanny))�c No, Npe Quantlty NR.Noi. <br /> JAV <br /> U4 <br /> cz <br /> 3' <br /> 14.Special Handling Instructions and <br /> r � <br /> d Additional Information _ r <br /> 15. GENERATOR'S10FFEROR'S CE"FICATtON:I hereby declare that the contents of fins owipnneni vn=luny and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper cond&r.for transport aanrfing to appttoabie intemationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I c rtify that the contents of(his consignment conform to the terms of the attached EPAAc;r:axpadgment of Consent. <br /> I certify that t*wWe minimization statement identified in 40 CFR 262.27(,}) I am a large q•.raniity generator)or(b)(if I ant a small quanly generator)is true. <br /> Ganerator's/Offerors PrintedrN ed Na S"m tum i Month Day ear <br /> �j 16,Internatn I hip menta <br /> 11 import to U.S. Expor,fnrrii <br /> Transporter skinature for exports only): Data laavtng U.S.: <br /> 17.Transport9rAcknowledgment of Receipt of Materials <br /> LU <br /> Tmnspoiter 1 PrintedrTyped Name 51gnawre� ;, Mnnth D.yy yew <br /> 4 1Fa sporter2 PrintedlTyped Narnt i$Ignalure Mo tft Day Year <br /> , <br /> 1e.Dlsarepancy ' <br /> 18a.Discrepancv Indication Space - ,. ❑Paul Ra- ❑Full RaiecHon <br /> ❑ Quantih- r?.: RR>•dwu .ief]inn . <br /> Manife_'t Referanu Number. <br /> 18b.Alteffate Facilily(or Generator) U,$,;:PAID Nun..ber <br /> C? <br /> Q Facility's Phore: <br /> w 18c,Signeiare of Altamets FauTiity(or Grner•,tof) Month Day Year <br /> 19.Hazardous Waste Rapart Managernent Method Codes(i.e.,codes for hazardous waste treatment,disposal,and wyCllnq systems) <br /> 2. 3, 4. <br /> 20.Designated Fc1clllty Owner or Operator-Cell of receiptof hazardous materials covered by trio rnarklast axcgpt as noted in Item 182 <br /> PrintedFTypedName��^''[[ $t�nahrra Month Day Yeaf <br /> EPA Form 8700-22-(Rev. )ev.M "•P.,fevinug editions are obsoletia. <br /> ( . „ - C.3,4NATED FACILITY 01(PENERAMR <br />