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i <br /> Please print or type.(Form designed for use n elite(12-pitch)typewriter.) <br /> Form Approved.OMB No.250-0039 <br /> UNIFORM HAZARDOUS 1:GrmerBtor Number 2.Page 1 of 3.Emergency Response Phone 4.M Kest 7 n <br /> WA�TEMANIMST 1 66M15 JJK- <br /> S{,�plm�Nameagdlr�fig,Add�ass <br /> P 0�w 33M <br /> G—Ax's Hft,Cao W3B4 8lusilot�.�A <br /> &Tracy mw 1 CON""wara! I US.FPA m Humber <br /> 49rif�s�l f.^elre+psl�t {�t.�d1l16dF+ <br /> 7.Transporter 2 Company Name U.S.FPA ID Number <br /> 44 <br /> US.EPA 43 <br /> .bat'++i1!6xwt&AV,ftA4ri LhC <br /> WMALOfK111R]7 A 757T8 <br /> FaciTBysRgne:f9fi9�7'�a-4'� <br /> 9a. %,U.S.DOT Description(includirg r gipping Name,Hazard Class,b Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Paddng Group(d any)) ,b Type Quarvaty WtNol. <br /> I. pa,k.l;.sC—C7A t—'id =o r1aW j CM ? 362 1 <br /> r 2. <br /> 3. <br /> 1 <br /> 4. f <br /> 14.Special Handling Instructions and Additional nbrmabon c <br /> ri r;ff?i?1r{Lu PgP•ii�t�t.'.::t t�)!'''?!P! 11''fil'.11i <br /> wadC PMW R P.E_ <br /> 15. GENERATOR'SwTEROwS CERTIFICA11ON: I hereby dedare that the contents of th s conillirment are fully and accu l ety described above by the proper shgrpirg name,and are dassded,packaged, <br /> marked and tabeledlplaraMed,and are in all respects in proper condition for transport acardia Itkppp W.raemationel and nationai govemmenW regulatrons.If export shipni-. and I ample Prima y <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached FPA AckwMedgment of Consent. <br /> I certify that the waste mkrimizauon statement idehtikad in 40 CFR 28227(a)(41 am a large quantity generator)or(b)(d I am a I quantity generator)is truo- <br /> GerwaUorslOfleror's PrintediTyped Name Signature Month Day Year <br /> 16.Intema8or a1 Shipments ❑&po t flan U.S. P Cf <br /> F– ❑Importlto U.S. ix"/exit: <br /> ? TrenspoYter signature(for exports only): Date leaving U.S.'. <br /> W 17.TrdnWorterAdatowledgment of Receipt of Materials <br /> Transport ypedName _ Signature .-a` Month Day Year <br /> Transporter 2 PrintedTTyped Name ! Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 1 as.Discrepancy Indication Space ❑ ❑type ❑Residue L__1 Partial Rejection ❑Full Rejection <br /> Mantlesi Reference Number <br /> 18b.Altemate Fatuity(or Gets U.S FPA ID Number <br /> U <br /> Fadiitys Phone: - <br /> W 18C.Signature of Alternate Paddy(or Generabr) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardas Waste Report Maragemerd Codes(i.e.,codes for hazardous waste beabnenC dspoaal,and recycling systema) <br /> uJ 12. 3. 4. <br /> P !32 <br /> 20.Designated Fadhry Owner or Operator tion of receipt of hazardous materials covered by the manifest except as noted in hem 18a <br /> Nntedrryped Name 1 tt Signature Month Day Year <br /> -71(Ja. ci i—i f5 <br /> EPA Form 8700-22(Rev.3.05) Pievious editions are obsolete. C$SIGNATEID FACILITY TO GENERATOR <br /> Ys <br />