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Please pent or type. (Form designed for use on elite typewriter.) <br />UNIFORM HAZARDOUS 1-GeneratofIDI'lurnber <br />i� t, <br />2. Page I of 3, Emergency Re4mise PhonMani <br />Fest 14. Manst Trackin-- <br />9 Number <br />WASTE MANIFEST Al <br />EPA Form 8700-22 (Rev. 3-05) Previous e&ms are obs6hte. <br />I I TR.kN-SFQR7TJ1'R nnv-*,r <br />GBF <br />5. <br />5. C?�7111110?'P:Ilame and M3" Addrm&-110� �A61 reEs fd differerd tan maRing address) <br />r, <br />ceneraws Phone: <br />6. Tw I Cofnpmry Namp- U.$ -HA fl) Nwnber <br />7. firmMorier 2 CwWry Nam U.S. EPA 10 Number <br />Desqwl�� and Site Address i7-U.SPA 0) Number <br />U.S <br />C, 1<: A <br />ga <br />9b- U.S. DOT Desch , fiodu&ng Proper Sdowm- Name, Hmwd Class, ID ftimber, <br />To. G mets <br />A-10181 <br />12- Unit <br />13. Waste- Codes <br />fiM <br />and Padmg Group "p) <br />Q".gty <br />WI.Nbl. <br />;L <br />Uj <br />2- <br />3. <br />d. <br />14. Sada! �Kdlerg Irsbuc@0r� Lions <br />15. GENERATOR'SIOFFERO now I. declare that the contents of this m-agnment we kly and awwately debt bed above by Ow proper std g name and are dassifi2d, padvaWd. <br />marked and to-beledfoarirded, and are is al respells in proper awHtfion for transport according to appkable witerraltanal and national governmental reWiatiorts. If e):pon shiflrr>ent and I am the PT.axy <br />Exporter, I me.W 6at the contents of ths consignment conium to the terms of the alladied EPA AdmooWgrnent of Consent, <br />I certify that the waste rninimizalion s!aterrvt iderMII-d in 40 CFR 262.27(a) f6 I am a large qua" generator) %Jb) ffl an a small quanty generalor) is Ifue. <br />C1ewiKv("MVwledrTyped Nam r Signahr R90 ut Day Year <br />16. krternatimal Stxpments 1-1 Import to U S. ❑ epwt ftmi 'i S. Port of entryiewt <br />L <br />Transporter %igrmure (far exports unlv): Date leaving U.S.: <br />UW <br />17 Transporter Advnvh" of Receipt of matenals <br />"- <br />1w <br />Transporter I PratfetDT Nan? .,. .1 sign—, "'os Day Year <br />f <br />do <br />TransporWz.Pmuewtypeu Name Signature Month Day Year <br />18. Disuepartcy <br />18a. Discrepancy Indication Space ❑ Q—tty Type. ❑ RLsed.e 0 Partial Rejecim El FO RJee. <br />Martfsest Rpfffwm Number <br />I Bb. Nterrae Facilily (or Generator) U.S. EPA D NLW&j <br />ti <br />Fates Phone: <br />W <br />16 Sqa3lure ofAftemate Fadiry (or Generator) <br />!Month Day Year <br />Vj <br />iq. Hq7xdws Vvbsta Report Management Wgiod Codes codes br hambous waste treatment, dmposal, and recycling systerns) <br />W <br />I t <br />4. <br />Ll <br />r <br />20. ctsip*d FBL%y oww v opum, cardmim of 04 hazim matmais m*red by tk- ma*& excW as noted in kn,8a <br />kiurh <br />Narne Signature Day Yew <br />EPA Form 8700-22 (Rev. 3-05) Previous e&ms are obs6hte. <br />I I TR.kN-SFQR7TJ1'R nnv-*,r <br />