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Please prat or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number - 2.Page 1 of 3.Eme,rgency Response Phone 4.Magifes( <br /> T5k' q Number <br /> JJ K <br /> WASTE MANIFEST <br /> 5.Generator's_Name-and.-Ma.iling.Ad'-",f 'i 'V(XK5*11r'EN Generator's Site Address(if different than mailing address) <br /> Al I TO P LAZA NA <br /> 1A <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPAID,NLwnbqr,, k, <br /> IF- 31 V1 LAI I <br /> 7.Transporter 2 Company Name L A 2-Ij&--I U.S.EPA ID Number <br /> 8.Designft <br /> jiip,1 jqame <br /> ,,a Ad ss <br /> U.S.EPA ID Number <br /> 0 w.A04j�4 t..ILAA> is k L L JAN <br /> ;A.;iWH'0N ,,iL ,� �'I'I I ",'A T 0-8 O'?1,? 5 2 <br /> Facility's Phone: I <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> ce <br /> 0 fi <br /> 3. <br /> 4. <br /> F-7 1 <br /> 14.Special Handling Instructions and Additional Information <br /> 0 tirij. j i a u�s4,AStA-INt-Lft <br /> AWROPRIAll L rt*Zi1S0fW PRUTILL,0 VE LQUIPMEN i <br /> I <br /> je <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 labeled/placarded,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 f, <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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)(if I am a small quantity generator)is true. <br /> G&nerators/Offeroes Printed/Typed Name Signature Month Day Year <br /> -j 16.International Shipments <br /> D Import to U.S. ❑Export from U.S. Fort of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter I Phnted/Typed Name Signature Month Day Year <br /> 0 <br /> CL <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> tY <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejwecti., <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL. Facility's Phone: <br /> LLj 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> !R <br /> Z <br /> V5(D <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C3 <br /> Uj 1 2. 3. 4. <br /> 1 1 1 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 7/Typed Name I Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />