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Please print or type (Form designed for use one ite(12-plich)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST Cd,?99009 E'r002 ! =x5-=4'•_12 CS 1005871080 JJ K <br /> 5.Generator's Name and Meiling Address <br /> is _ T �r --,m f �f LS `1:: - -_ <br /> Genera ors Phone "s I ' :4. 5n=7 -: <br /> 6.Transporter 1 Company Name U S.EPA 10 Number <br /> 'r �t:irtrllrFcrl*�I $er»ti��; 7 <br /> 7.Transporter 2 Comoany Name <br /> B.Designated Facility Ne a and Sate Address r <br /> I f-&t^ z_ r�r+_t. _ — <br /> Fac .'s Phcne <br /> ga 9b.U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12 Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt Nol. <br /> 1' ft n-f:CR tezardi:-m wnL-s Viutd f���i1 CIL) l .�:c _- S b i!V <br /> z 2 <br /> ry <br /> r <br /> 3 I <br /> 4 I� <br /> 14 Spec;al Handling Instructions and Additional Inlormation <br /> nza—:- rer:4 ilk:t L:fQfC+: :; ttij'37_h L:eadT FI1F-hp. cf- P <br /> 190Y- 26 ILt-.5— <br /> A/ <br /> 15 GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this cons$gnment are fully and accurately described above by the proper shipping name,and are classfied.packaged, <br /> marked and labeledlplacarded,and are in all respects In proper condlt3on for transport according to applicable intemationai and national governmental regulations-If export shipment and I am the Primary <br /> Exporter,I certfy that the contents of this consignment conform to the terms cf the attached EPAAdmow[edgment of Consent <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a){d I am a large quantity generator)or(b)(if l an a small qua g Werator)i true <br /> Generator SlOfferors PrirtedlTyped Name 8ignatute Mont) Day Year <br /> -1—i''i"' - i3--f i rr TI IDC 314 {T TI-c- ly_ %N 1 r-, <br /> 16 lnlemationai SKpmenls <br /> z ❑Import to U.S. ❑Export from U.S Pad of entrylect: <br /> Transporter signature(for exports onlyy Dale leaving U S <br /> LW 17.Transporter AckncrLedgmentofReceipt ofMaterals <br /> Trarsporter 1 Prinled+Typed Name Sienatura Month Day Year <br /> N �? S 1 i <br /> Q Trans,;crler 2 PrintedlTyped Name Signature Mcnlh Day Year <br /> a <br /> M <br /> 18 Discrepancy <br /> 1 B Dis p ndicafon Spa e - <br /> � <br /> t? 11, �% Ir~� 1>t Glc -f � o n fir-Z IP—ISI t,4 <br /> le <br /> 18b A;tema!e Fa " or Generator <br /> J <br /> U <br /> LL rac,itysPhone <br /> 1:1w 1BcSignalureofA!temateFaaiity(or Generator) Month Day Year <br /> a <br /> z <br /> N19 Hazardous Waste Repan Management Method Codes(i.e.codas for hazardous wasts treatment,disposal,and recyding systems) <br /> wi <br /> 1 2 ) <br /> 20 Designated Fa6ity Owner or Operator.Certification of receipt of rdous*rials covered by the manifest except as naad in item 18a <br /> PnrtedlT}ved Name <br /> EPA Farr 8700 22 Rev 3 05) Previous editions are obsolete 1 i{7 EIEST <br />