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Please print or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved.OMB No.2050-00 <br /> UNIFORM HAZARDOUS 11.Generatoi ID Number 2.Page 1 of 3.Emergency Response Phone .Manifest Tracking Number <br /> WASTEMANIFEST CAOQ1Dy) -- I611510-+b3- &36'1T 000257467 MW <br /> 5.Generators Name and Mailing Address Generators Site Address(d different then mailing address) <br /> q(�4B A1� gRD I�AA-yHf}nlA� M(/l/! LLC . I��iG�, /J ►`3 ' t�4v"14` �1i rr <br /> sire� Q A), - �I.s�v?-�> S-vo c 1<'To lsj/ <br /> Generator's Phone: t b S <br /> 6.Trans r 1 Comps y Name U.S.EPA ID Number <br /> i <br /> 7.Tans iter 2 Company Name U.T.EPA ID lKmbeT <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> G eft N H.i4 R& A-s <br /> .2•YZCl W LOP-= Ab <br /> F.AsYhV 7L21 4) <br /> ga, 9b.U.S.DOT Description(Including Proper Shippkg Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Padang Group(i(any)) No. Type Quantity WtJVot. <br /> 1. <br /> 0 ��� � ✓?� --- --- <br /> hb H C 14 A w jets r , c ( cn.� y <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Add' nal Information <br /> f' <br /> USE <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and an i in all respects in proper condition for transport accareing to applicable inlemetionel and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I car*that the waste minimization sts tement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratceslOfferors Printed7Typed Name Signa Month Day Year <br /> 16.In national Shipments <br /> ❑Import to U.S. ❑Export <br /> from .S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransponerAcknowledgmenlofReceipt Materials <br /> Transpo 1 P intedfTyped Name Signature nth Day Year <br /> Z TransporW2 PtinW I YPLO Name MoM Day YeAr <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type Residue Partial Re1econ Full Rejection <br /> Manifest Reference Number. <br /> 18b.Allemate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facifity's Phone: <br /> W 18c.Signature of Alternate Facility(or Gene rali Month Day Year <br /> Q7 <br /> Z <br /> H19.Hazardous Waste Report Management Vlelhod Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C L 2. 3. 4. <br /> 20.Designated Facility Owner or OperatorCertification of receipt of hazardous materials e^vered by the manifest except as noted in Item 18a <br /> PrintedtTyped Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF RE0111RF:n) <br />