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Please print or type.(Porto designed for use on (12 Pte)tYP ) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID umber Z Page 1 of 3.Emergency Response Phone 4.Mrdfa tTradnring Number /�\J�/ <br /> WASTE MANIFEST r 1 : Z ; 01:J 15 7'v C4 1 r�y I <br /> 5.Gerwatore Name and Alaifeg Address Generators Srle kkftssr(K didenard then melt address) <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA0 Number <br /> 7.Transporter 2 Company Nome U. . Number <br /> 8.Designated Fa6fily,Name and Site Address U.S.EPA N Numbs <br /> F , Phone: y c.J s..�. f <br /> r <br /> ga. 9b.U.S.DOT Desarytion(nduding Paper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and 9�+P(d an}')) No. Type Quantity WLAfd. 13.Waste Codes <br /> 1. <br /> Z 2 <br /> W <br /> 0 <br /> 3, <br /> 4. <br /> 14.Special Haring trrstr bons and Addltond klimnabW <br /> 15. GENERATOR'SIOFFEROR'S CERTiFICA I hereby dedate tat de rnrrtonts at dike axnnsajv en t are My and a=rately described above by the Proper stKppirg namae ad are dawdled,packaged, <br /> marked and�ledlplacarded,and are fn all in proper cmxftn for M%port according to appirable wrlerneliord and n governnherdd reguladorm if apart K and I am the Prvnay <br /> F�orter,I re*that One cmKahts of Itis t=ftm to the Ears of the aftadhed EF%Aclmwdedt;TwK of Consent <br /> I certify Nal the waste mnimmation staleaaerr(identiBad in 40 CFR 26227(a)(d I am a large quantity generah3r)or(b)(KI am a small quanhdy generator)is true. <br /> GerwatorslOffines Printed/Typed Name SignatureMonth Day Year <br /> f <br /> 16.k lernahonaT hphents ❑Inpat ttq U.S. ❑EV d from U.S. Port of-*yf wt__--__ <br /> Transporter signakue liar exports only): Date leaving U.S.: <br /> W 17.Transporter Admowtodgnera of Remo of Mah4 tAs <br /> I& TmnVoreer 1Name S91akra Moth Day Year <br /> o7 <br /> CL t, , <br /> QTransporter 2 yped Name Sigretrae Ydar <br /> 18.Discrepant' <br /> tBoc Giscreporhoy Indication Space ❑ Qum ❑Typo ❑Residua ❑Partal Rejection ❑Full Rejec>ion <br /> Manifest Reference Number. <br /> 18b.Aheate Fadfdy(or Generator} U.S.EPA ID Number <br /> J <br /> Q <br /> LL FaaWs Plane: <br /> W 1 K.Sootu a of Alternate Faddy(or Generator) Month Day Year <br /> Q <br /> Z <br /> Of 19.Hazardous Waste Report Management Method Codes(ie.,codes for hazardous waste lreatma K,disposal,and recycling systems) <br /> O 1. 2. 3. 4. <br /> 20.Designated Faddy Qwner or Operator.CatUalion of receipt hazardous nalansis omwo by the rt except as noted in Item 18a <br /> Prntekf/iyped Names Signetore Month Qlay_, Yew <br /> . /Jam.. _ ..--•""' -� <br /> EPA Form'8&22(Rev.3-05) Pr%ious editions are obsolete. TRANSPORTER'S COPY <br />