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7 t 4s' <br /> Please print or type.(Form designed for use on elite(12-piwiq typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 77FT Emergency Response Phone 4.MaRife t Tr ckin Number <br /> �`(� c�(c <br /> WASTE MANIFEST ;f ;.; yi `.t3! ? i i_..i'001. =,i_,�t- 1 tfie{ V b 10597`i 9 7 V IAV <br /> 5.Generators Name and Mailing Address Generators Site Address(if different fferent than mailing address) <br /> fa <br /> . Fits T f=S <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> �i':'-'":.) �;--it.e._r.-�-:iii .�+•i";'�i��r°)�'i.. h"�', Tnf:it'@`1'�jl;.illJ'��;S1i <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 1 <br /> 8.Designated Facility Name and Site Address ; �... r- U.S,EPA ID Number <br /> 4161 1 <br /> ! X _ <br /> r1tt�7j.. i {tii�? 7 71 <br /> Facility's Phone: <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> �1 _ — <br /> W 2 J <br /> �y( i �y � ,Jv� •�` Y�,I <br /> �.� <br /> J !.1 ,).- <br /> 3. L.. <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information PCC 01515N•3.8,1 57)L s_.e:1 J L f tLi4rf ' '7 <br /> f SA i"Y- EN -- Ct ;PAf 4 >8) <br /> i-I i.�..S: j�) _,.,tit ,r-r !:�i 113f-417 , h1'• F!1 m';t,-'; - ,;.{/.7 C - u_ c <br /> 15. GEN ERATOR'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 /> Generators/Otferor's Printed/Typed Name Sig ature Month Day Year <br /> 16.International Shipments <br /> F- 11Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17,Transporter Acknowledgment of Receipt of Materials <br /> TranV,�,f <br /> r 1 Printed/Typed Nair / Signature i %... Month Day_ Year <br /> no ��i% I J '� �—'—" j' <br /> Q Transporter 2 Printedffyped Name Signature Month Day Year <br /> H <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quant ElT e <br /> Quantity 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 /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 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 /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />