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Please print or type.(Form designed for use on Oft(12-pitch)typewrites) Form Approved.OMB No.2050-OM <br /> UNIFORM HAZARDOUS 1.Gtrrtere[or ID 2 Page 1 of 3.Emergency Response Plane 4.M d W Traddng Nwaber <br /> WASTE MANIFEST !��. "� , " f ,�i /1 000257463 M W <br /> 5.Generator's Name and Mailing Address r Generators Site Address(d dflerent then mailing address) <br /> :_:• „ .1.r, .1 i' ri't, I ��..- j s !_, -.,j• ' i i .. �-• �- <br /> Generator's Pbow v`.1I t.. <br /> 6.T r•��M 041u<, U.S. <br /> % �. <br /> 7.TranWorlef 2 Company Wme U.S.EPA ID Nrmn6ei <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Nmmdber <br /> r s <br /> Faditys Phone' <br /> ger 9b.U.S.DOT Description(nchdnrg P Slipping Nana,Hamid Class,ID Number, 10.Containers ners 11.Trial 12.Uri Warta rta Codes <br /> HM and Packing Group(dant)) � ippinNo. Type Duarntity WtNol. <br /> 1. • <br /> i r - <br /> Z 2. <br /> W <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handing Instructions anclAddi nformation <br /> 16. GDiERATOWSAO)FFERORS C THM:t hereby dedae mat the mints d tits oat9grmrent ore fuiy and acaaakiy described above tryOne proper shyping name,andaredlassW pecl aged, <br /> marked and lebeledlplacaded,and are in respects In proper ca "on for transport axx rdmg Io W*able tnftnetiertal and national Woor mental rag f tns.M export sldprnent and 1 am the Primary <br /> Exporter,I d�tldy that fie dxxtads of Bis cardam$Dthe terns of the Mchad EPAAdmwaiadgm M d Carsent <br /> I certify t W the wasia minimization identified m 40 CFR 2U27(a)(d I am a large quadiy garandor)or(b)rd I an a small quantity gwwator)is true. <br /> Generators101ferors PMWffyped Name Signa tu a Montin Day Year <br /> J 16.IrdenuiUonal Shipments ❑ to U.S. ❑Export from U.S. `Pari of entry/exit <br /> tTdarrsporter apnat-(for exports only): Date leaving U.S.: - <br /> 4' 17.Trarspona AdvxWedgrrent of Receipt of <br /> T 1 r ti1 � 7 1) <br /> 1Year <br /> 7;•- <br /> zQ Trarsporte PrinledlTyped Name Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ ❑Type ❑Residue ❑Partial Rgad. ❑Full R*dim <br /> Ma lest Reference Number. <br /> 18b.Allemalle Facdnty(or Generator) U.S.EPA ID Number <br /> .:r <br /> aai Facility's Plane: <br /> 4 <br /> W 18c.Signature of Alternate Facility(or Generator) w Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Codas(i.e.,codes for hsmndars arae beatinant,dspoeat,and recyd ing systems) <br /> C 1. ( 12, 3. 4. <br /> 20.Designated Facility Griner or Operator:CeklkatiDn of recatpt of hazardous materials by Bre mw&st exoepf as ncted to item 18a <br /> PnnWyped Name svwbre Month Day Year <br /> . f t <br /> EPA Form 8700-22(Rev.3-05) Prwous edi*w are obsolete. TRANSPORTERS COPY <br />