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Please print or tvoe. (Form desioned for use on erste (12 -Ditch) tvoewriter.l <br />i /-• r <br />Alf <br />1 1) T <br />Form Aooroved. OMR No 2050-0039 <br />UNIFORM HAZARDOUS 1. Generator ID umber <br />2. Page 1 of <br />3. Emen3ency Response Phone4. <br />Martifest TrwddnNumber <br />a.16 6x74 35 3 J <br />WASTE MANIFEST 4 . <br />4AI5 <br />-JK <br />6s"=ne and Mal ng Addresss NOWOwmaTiig address) <br />.� . . .. <br />.. <br />CA.f..V+JV4 f M <br />7. Traspdr(aZCmpagl�l"e- <br />U.S.EPAIDNumber <br />9.94 cis <br />x <br />;. C <br />US �!l Nombet//�.yy. <br />''N1.- <br />v` <br />. <br />ga <br />1fS_6bt a 9i�t8i(aiie\\ttamrd CSS ID Phr< w <br />10_ eabbe s <br />11. Total <br />12 Unit <br />13. Waste Codes <br />No. <br />Type <br />Hid <br />sW Pad _. . - <br />Quantity <br />WINol- <br />1. !h -W <br />1 <br />CM <br />T <br />152 i <br />LU <br />z <br />2 <br />t <br />� <br />t <br />14. Special Har&N Instructions and Adddronal- <br />Invow Pmpw P.Pf-_ t cm4mim <br />15 5 CERTlWA : I hereby declare Clot the eoatents of this corsfgrvrent are hilly and accurately desaihed above by the proper shipparg rka". and are dasAm, Padmged. <br />marhad and labeled/placarded, aril are in a1 r spects in Pieper condition for transport. according to applicable ih� and national governmental regulations. If export shipment and I am the Primary <br />banter, I certify that the wNents at Cis cons pvnerit conform to the terns of the attached FYAAdmowieogment of Consent <br />I certify that the waste mk&niration sta mord datlied it 40 CFR 25227(a) (d I am a large qua * generator) or (b) rd I am a smallgenerator) is hue. <br />Genera �PrintedlTyped Name ... S grhature <br />_ <br />Mach Day . Year _ <br />- <br />.: . <br />-x 16- International Sfip"Iehts <br />[:- ❑ iifpmr - U.S. ❑ Export ham US. d day/exit -- <br />Transporter signahue (W sports o*): Dale leaveg U.S.: <br />w 17. TrasporlerAdmd*dwod of Recepi of <br />f <br />Transporter 1 Pdnted/TypedBaine <br />�' <br />Moan " Year <br />116 <br />Transporter PnmtedfTyped Naive <br />Month Day Year <br />18- Discrepancy _ V <br />18a. Discrepancy Indication Space Quan*yType ❑ Residue <br />❑ Partial Rejection <br />❑ Fut Rejection <br />Manifest Reference Number. <br />786. Alternate Facility (orGenerator) <br />U.S. EPA ID Number <br />J_ <br />V <br />F.W. Plane: <br />W 18r- Sgnatt" of Aftemate Factity (or Generator) <br />Month Day Year <br />a <br />z <br />N19. Hazardous Waste Report Management Method (i.e., codes fir hazardous waste treatment, disposal, and recyckg systems) <br />LU 1 <br />!32 <br />In <br />3. <br />4. <br />20. Designated Faalty Owner or Operator of receipt of hazardous materials covered by the manifest except as noted in stern 18a <br />Printed/Typed Name t j0'-� j-+� l./ � � <br />f <br />Month Year <br />/� <br />� V'III <br />EPA Form 8700-22 (Rev. 3-0S) Previous editions a e obsolete. <br />DESIGNATED FACILITY TO GENERATOR <br />