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Please print or type.(Form designed for use ot elite(12-pi )type Ofec) Form Approved.OMB No.20513.0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number . 2.Page 1 of 3.Emergency Response Phone 1kM&1~TnicwngNwnbff <br /> WASTE MANIFEST y rr) j ! j. 4 tis r, 000257461 MW�' <br /> 5.Cwaabh Name and Making Address Generator's SIMAd*m(f dilliamrri titan�9 address) <br /> GeflBratDra Pllale' , s`�. - 1 f ._ r - <br /> 6.Transporter 1 Company Name., r' U.S.EPA ID Number <br /> r <br /> T.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.FPA fl)Number <br /> L <br /> FadWs Phone: – <br /> 9, 9b.U.S.DOT Description(Mdudug Proper Shipping Name,Hazard CIS,ID Number. %Contaerers 11.Total 1z" 13.Waste Codes <br /> HM and Packing Group(3 any)) No. Type Quantity WUVoI. y <br /> 1. 1 <br /> Z 2- <br /> LU <br /> W <br /> C7 <br /> 4. <br /> 14.Special Handling Instructions and Addilionet Irdonnabon <br /> 15. OENERATOWWOFFEROWS CERTWCATPW I hereby declare that the contents of this ansigrunent are fully and accurately described above by the proper stuppirg name,and aro daSS&K4 padraged, <br /> marked and tabeledlptacarded,and are n aglrespeda M proper mdi8ai lor transport aomrdrrg to a ppficable ntemational and naborW governmental reg<nlations.9 exprd shipment and I am the Primary <br /> E)Portef,I certify that the contents of Nis coosigninent conform b the tens of theatradted EPAAdmaMedgrnent d Ca ment r <br /> 1 of*that Waste MM12mon &mffed in 40 CFR M-27(a)(if I am a large quay*generator)or(b)(if I am a srreB quantity generator)is true. <br /> GerreratorsfOlferors Pdnted/ryped Name Signature Month Day Year <br /> _a 16.International Shipments <br /> F ❑import to U.S. ❑Ecport from U.S. Port of entrylexft: _ <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TranspoderAdmo0edgimrriof Receipt ofMalanals <br /> Transporter 1 PdrrtedfTyped Name Swab- Moro Day Year <br /> CL <br /> Transporter 2�rinted/ryped Name Signature Month Day Year <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Qua(rtity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Mandest Reference Number. <br /> 18b.Atlarrale Fa*V(or Cwwator) U.S.FPA nD Number <br /> J <br /> U <br /> aai Faa%?s Phare: <br /> C3 18c.Signature of Alfanate Facff4(a Generator) I Month Day Year <br /> a <br /> z <br /> ti19.Hazardous Waste Report Management Method >x1es(Le.,codes for hazardous baste treatment,disposal,and recycling systems) <br /> LU G 1. `` 2 3. 4. <br /> t..tl� <br /> 20.Designated Facility Owner or Operator.Ceetifics ion at receipt of hazardous materiels covered by fie rrrarr est except m nded' item 18a <br /> nnted/ryped Name \ Signature Month Day Year <br /> EPA Form 87022(Rev.305) Previous editlons are obsolete. TRANSPORTER'S COPY <br />