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.� <br /> 1-07 0 <br /> Please print or type.(Form designed for use on 01ite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS1.Generator ID r 2 Page 1 of 3.Flnergerrry RaSponse Ptwne 4.IhUndeerl 6 lrnber <br /> �5 ��� <br /> WASTE MANIFEST (f jj 7 <br /> 5 erre and Mailing Address jif dlbWt ttren mating address) <br /> ei Mlgllft#" <br /> .vw- •+.�... ',tet ,w:w - .� <br /> 7.Tralsportu rTCanpary Nate U.S.EPA IQ Number <br /> '�~ - <br /> r <br /> r p.. ac ¢ � <br /> _ 0. �llDpmbtT .y." <br /> Ay 5 T/ <br /> f a <br /> fi3igPwpdr.Shwirgftae,Hazard Class.m Nurnber. 10:Corga�rs 11.Total V.un t <br /> HM aid P�9�P Pr� No. Type Qum" WlJVd. 13.Waste Codes <br /> 1 W, )ti R-CgA Nen. ftn Weft t5 FAQ/ON his) t Cm T 352 ! � <br /> z 2. <br /> W <br /> 3. <br /> I . <br /> 4. <br /> 14.Special Handling Irsimctions and Additional Infolmation - <br /> :• t�•a�'17_�Wba� P.P.�. fi�'�t'f�T9� _ <br /> ti4 ' SOS" ' <br /> 15. GOERATOWS10FFEWR'S CHti1MTI":I hereby declare that the contents of this ars gm ent are fully and accurate-4y described above by the proper Shipp ng name,and are dassiri ,padraged, <br /> marked and tabeled/piacarded,and are in all re0ects it proper condition for transport according to applicable w4wnabonai and national governmental regulations.It export stripment and I am the Primary <br /> Exporter,I cartity that the cordenis of ttns conform to the ferns of the attached EPAAtlmowtedgment of Conran. <br /> )certify that the waste miirriatiort swerrternF�in 40 CFR 28227(a)(4I am a large qum*generator)or(b)(dl am a small qeneralor)is Yue. <br /> Geabn sl0femrs PrintedfTyped Name Signature Month Day ,Year. <br /> F - N b f <br /> 18.International Shipments <br /> F- ❑Import m U.S. �Export from U.S. P d entry/exit <br /> 1 ransporter s4natum(for exports only):. I Data Waving U.S.: <br /> LO: 17.TiarspoAerAdtnri mentof Receipt of / <br /> IX TransporterI PrintedlTyped Nametvbnth' Year <br /> CZ C� �Q 26 <br /> Transporter PrintedlTyped NM* ure Month Day Y6ar <br /> tr <br /> t- <br /> 18.Disompency (� <br /> 18a.Discrepancy Indication Space Type Res due ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(orGenera(pr) U.S.EPA ID Number <br /> J_ <br /> V <br /> W Facilitys Phone: <br /> I= 18r..Signature of Aftornate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 01. 3. 4: <br /> I3� <br /> 20.Desgnaled Facility Owner or Operator.Centifrcaiiop of mck*, of hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> Printed/Typed Name s9nahnre Month DA fear. <br /> 6 �� c4 16 T <br /> EPA Form 8700-22(Rev.346)Previous editions arO obsolete. DESIGNATED FACILITY TO GENERATOR <br /> e <br />