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i <br />Please print or Woe. (Form designed for use on elite 2-ndchl tvnewrriter.l <br />Fnrm AnnmvAd OMR Nn 21KIS nr.A9 <br />UNIFORM HAZARDOUS 1. Generator ID NGmber <br />2. Page 1 of <br />3. Funergency Response Plane <br />4. ManrTest !Cumber �s+ <br />WASTE MANIFESTI 11-Q <br />, 6.4 .,, V JJ K <br />5. Genenators Name and Matitg Adifress - s (d off ent ttari mai<rxj address) . <br />Uc'I <br />- all& <br />-4- <br />7- <br />7. Transporter 2 Company Name D.S. EPAID Number <br />i i4 `Te yi4'. ',4-'. �+,ws.?-=fr_ �'``�',-.�, '.•yam' �d .2.HJ�1'"�:ft 'F$'} h"?"0.'^`r@• Qct. ?"�4��•'S%S"�'+' . <br />p� <br />NMI PPAT&W U.SL ~7061111w <br />ME. ME <br />Sk U S DMD-*ffnit f *&s rg Floper SfrOM Horne; FAwad Cris, D MxubK <br />10-�Italilel5 <br />11. Total <br />12- Unit <br />13. Waste Codes <br />1,10. <br />Type <br />AM�9 <br />C4? <br />Quantity <br />WVvd <br />% <br />fjs�it3� <br />,tt.r <br />I <br />r <br />s. <br />t <br />+4 'e <br />, <br />I Hardt Inshuctions- Additional (n <br />1 a n and <br />� 9 _ <br />---G:. - <br />h--., a. y i .tet :7-: <br />15. G M CER FKANOH: 1 hlereby declare M the torments of this carsignment are fully and ac=A* described above by the proper shipping name, and are citassifed, packaged, <br />mal,od and iabetedfplecaiied, and are in al raWects in proper corKralon f w transport according4appkabie rcrtemat oral and national govemmental regulations. If export shipment and I am the Primary <br />Fporter, l certify that ft contents of this corisigwoit conform to the tensa of the attadred EPnAdMwledgment of Consent <br />I certify tint tine waste uwftration statemeffl kWdVpd in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (d I am a sinal quantity generator) is true. <br />GeneratorslOBeroesPrertedfTypedName SignaturefP ! Morth Day Year <br />Ka-fdo"I I <br />.J 16, inter[raliorrai S}tjprnents rj I ❑ Export from U.S. fry <br />mpoFttoU.S. en lexrt _-- - <br />Zu <br />- Transporter signature (for exports only): Date leaving U.S.: <br />LQ: 17. Transporter AduwAedgmeld of Receipt of Materials <br />Transporter 1 PrirttedlTyped Name t mato e M{th Day Year <br />a <br />L�(J <br />QTransporter 2 Printed/Typed Name Month ay Year <br />a <br />18. Discrepancy _ <br />tr <br />18a. Discrepancy Indication Space LJ Quantity ❑ Type ❑ Residue LJ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />H 18b. Aftemate Facility (or Generator) U.S. EPA tD Number <br />U <br />LL Facility's Phone: <br />W18c. Sgnahrre of Aftemate Facility (or Generator) <br />Month Day Year <br />zz <br />55 19. Hazardous Waste Report Management Method Codes <br />.e-, codes for hazardous waste treatment, disposal, and recycling systems) <br />0 1. <br />�! Y <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator Certification of leceipf of hazardous materials covered by the manifest except as noted in Item 1 as <br />Pnrriedr7yped Nine -signature Month Day Ysar <br />EPA Form 8700-22 {Rev. 3-05) Previals editions are obsolete. - DES;I.NATED FACILITY TO GENERATOR <br />k-: <br />