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-0-- <br /> Please <br /> -Please print or type.(Form designed for use on elite(12-pitch,)typewriter.) Form Approved.OMB No.2050-0039 <br /> T UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number �( <br /> WASTE MANIFEST li�;j�}',7`>r�i'i�`.! ? {. -1;�';it7...�t,f:�rj .t 1.f,6:9 SI`c <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) v <br /> 1. 1V 7i s)ke i.f <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> tiaiirl"hs>'l�i 1 c'k1'�, <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. <br /> CL' IVItJ ;,i ��lq {�.'.r�i�i)i_lli'._ �ili'.� 1t-- I 7 i. <br /> ''i,; C Nrt <br /> W ' � <br /> Z 2. <br /> W <br /> (9 <br /> 3. <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Information i, c <br /> V 13 <br /> 14 HR. #1 8�!'�?I•-i4,f', i 7(,G'I <br /> F , <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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international 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 certify that the waste minimization statement 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 /> GeneratorslOfferor's Printed/TypB8d Name Signature Month Day Year <br /> r" i . <br /> J 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> OTransporter 1 dnted/Typed Name Signature Month Day Year <br /> ZTransporter 2 Nntedrryped Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> rn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous,editions are obsolete. GENERATOR'S INITIAL COPY <br /> 1 f'11: 1 , -:it <br />