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Please print or rm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.Manifest Track Number <br /> WASTE MANIFEST a ate ID r r `02 1 840 1569-977-6282 <br /> 0 0 5 5 3 6 G B F <br /> ftSt-*Mg4nd-A1auiNV,stL P Generator's Site Address(if different than mailing address) <br /> 49W 13UCKLEY COVE <br /> sT KTON. (_AI 67 <br /> Generator's Phone: 1 <br /> 6 Transporter 1 Company-Name Service r . <br /> 'AA6 <br /> 7.Transporter 2.Company Name 7 U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> SRI Recychnq Service Inc WIR000029751 <br /> 101 Naf4en Or <br /> Woodville, VAI 54(V8 OLIO-2141-2(_14 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1. <br /> P Z23 <br /> Z 2. <br /> L <br /> 3. ".' <br /> l F <br /> CRMCATE <br /> 4. <br /> Mecial andfn Instruction ndq�djtional Inform 8 <br /> r rot c ove �Crt�lfnp . n l_Pyewearr_ OILY ABSORBENT <br /> 15. GENERATOR'S/OFFEROR'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 <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 /> Generators(OfferorsPnntedFfypepJNjI,- > (� t Signature �'/ // Month Day Year <br /> x'��� �IJl1� ' '�i! { ,P Vt�Jk f I� V�l ��'�i <br /> J 1 16.International Shipments t <br /> Z 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> E 17.Transporter Acknowledgment of Receipt of Materials <br /> Fe TranSignature?1 Printed/Typed Nae Signature Month, Day Year <br /> a Jl �C_4 A ,iJ 1G�G�.v f G �c �r1 ! 3 Cin( <br /> rn <br /> Q Transporter Printed/Typed Name Signature Month Day Year:, <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> II�^, I ❑ ❑ <br /> Residue Partial Rejection ❑Full Rejection <br /> L �1 Y) o-c I j1 GL1'rY�.ct �..rL,� ��a YC ( fV-VC1Y- <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 1 <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 2. 3. 4. <br /> `x40139 <br /> F <br /> d Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as notedin. 18a <br /> NameSignature_- —'' -- Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous edition are obsolete. i <br /> DESIGNATED FACILITY TO GENERATOR <br />