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Form Approved. OMB No. 2050-0039 <br />11V4u <br />1 Generator l0 Number "_.-..._..,, „ <br />UHA2AR000S . <br />UNIFORM <br />2. Page l of <br />,.. <br />3. Emergency Response Phone <br />4. Mail st mcking Number <br />00101H72 <br />DAT <br />WASTE MANIFtST <br />5. Generator's New and Mailing Address Generators Site Address (if different <br />than malting address) <br />OPI9fo1i4A2 ;let <br />-al <br />Generators Phone: '. , i.• •.r,"' ^� _ ':�y., <br />6. Transporter l Company Name <br />U.S. EPA ID Number <br />7. Transporter -2 Company Name <br />U.S. EPA ID Number <br />r _ a c -/C <br />cn iA6� <br />8, Designated Facility Name and Site Address <br />US. EPA ID Number <br />_ r' <br />Fadlitys Phone: g'..,:.• )' 1-�[ 1(. srt <br />,,liUulyllb <br />gra <br />9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, lO Number, <br />10.Contafnam <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNol. <br />1. <br />fp.� <br />j• <br />— <br />NMW <br />-- <br />—. . <br />4�N W <br />rcrn <br />3. '. <br />3(I�W <br />YClYf <br />4.ji <br />IHN1N <br />-Y/qr <br />i <br />-14:Speclal Handling lnshuctoris and Additional lnforinatidn"'- - - -""' - -- -" -_ _-"' "- - "--"' <br />-""-'--"'-- -'--- <br />"- --"---'-' -- <br />. <br />ssr i. <br />16.. GENERATOR'SIOFFEROR'SCERTIFICATION;,Iherebpydeclhal the contents of this consignment are fully and accurately described above by the proper shipping name, and she classified, packaq'ad, <br />aretcondition <br />marked and lebeledlplacarded, and sura a�rpspeds in pm par for transport aocurdIrl to applicalle International and national governmental <br />regulations.If export shipment and I am the Primary <br />Exporter Icertify Oat fine- contents of lhls consignment conform to the terms of the attached EPAAcknowledgmedof Consent - . <br />I crudity that the mate minimization statement identified In 40 CFR 262.27(a) If I am a large quentlty generator) or (b) (if I am a small quantity <br />generator) is true, <br />- <br />GehendoeslOfferore Printedlfyped Name i Signature - <br />- <br />Month Day Year <br />fly .I Ir <br />-pi <br />i- <br />=Transporter <br />16, InIeffirgirgalelehipmei- <br />Import to U.S.' ❑ Export from U.S. Pod of entrylexit: <br />signature(for exports onty): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />C <br />Tr napoter1 Pdnted pe Nema, S(gnafNr� <br />Month Day Year <br />earr- <br />w <br />Tra er 2 P nted/typed Nems.._ Sighs e <br />/, <br />moth Day � YearZ <br />� <br />1ti'biscrepancy - r <br />18'.pisclepency Gdfdatlon Space Residue <br />Qlailyi <br />/ El Type <br />_ Oporto] <br />❑ PeNal Rejection <br />❑Full ReJectlon <br />/y� �" 1- -f' est Reference Number. <br />A, !tJ iJ i Manifest <br />18b Alternate Fidlity(or Generator) / <br />U.S. EPA ID Number <br />f,1, <br />-r ,+ ! �r .J-. <br />' <br />'. /' � <br />rl�` J <br />raa. <br />Faclhtys Phone: •�y . 'f i„( <br />3 Q <br />W <br />18c. Signature of Alternate Facility (or Generator) <br />Moth Oay Y, <br />19. Hazardous Waste Period Management MethadCodes 0i codes for hazardous waste Vestment, disposal, and recycling systems) <br />C. <br />1.. 2.. 3. <br />4. <br />20 Designated Facility Owner or Operator. Cedificafipn of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />- <br />I <br />PnntedlTyped Name Signature <br />Month Day Year <br />EPA Form 8700-22 (Rev. M5) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />