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<br /> j?lease printot,ty .(Form da§lgned for use aiti e0t�'�12-p13Ch,lYpe�iijfer y .. : . ;'.. • . .... Form Aoproved:OMB No 9050.0039
<br /> UNIFO . NA7RRDOUS' 1;Ganerafor#D tuba 1 y� 2 Page 1 of ;3.P�e4ge�nPc 40voSe�P-bp,e 4 Manrfest Tracking Number.
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<br /> .8.Transporter 1CompanyName U.S,FPA ID Number
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<br /> 7.Transporter 2Company Name" U.S.EPA ID-Number.
<br /> 8.Designated Facility Name and.Site Address.. U.S.FPA ID Number
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<br /> U,SrDOTDescflption(induding P'roper,Shipp16 Name,•Hazaid'Ciass;ID Number, 10.:Containers'. : 11.Total '"12.Unit
<br /> and Paddn Group if an ; 13,Waste Codes
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<br /> • 14 Spgdiat;:HandlinglnsUuchons�nd ddl6o�taf�informaUon , ti.�i :;Y -1 ri ��� ":� '� ��:%�,:"v .. ,
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<br /> 95 GENERATOR SIQFFEI o[ZSS Ct31 Jl`iCAfidtil�7fiaredy.deciare fhatthe:011fe tsrof tq�s cotisignmont are;fulty and accuratefy.des'a b'edabova by ihs proper.shipping name;att are classified,packaged,
<br /> mcondihori for lransporf accdYtlingio apphcab(e inteMaik natand natlonal'govemmental regulations•if export stifpment and tam the Primary.
<br /> F?c{aortenslgpVwconorftoth'e':twleofEhe'aitachedEPAAcknowledgmentofConsent
<br /> I cartfi�lpat theturastemtitirfiftailart9fafinent#0nt1'fied.jn 48 CFR;�8727(a)(rfi ama large quanfdy gen6ratot)or(p�if i am asmaj quantity.generator)Is True: .,i • .
<br /> Gan #b7( sPrnf Rypetliamefr �, j rtC {ya Signature,^ Month Day Year
<br /> �.18;liitetnatioti Sh�pmenis + ' --...,i "�' ' ❑imp6ttto U S ❑Export from U S; Port of entry/etdf:. '
<br /> Tmnsportersignaturff:(forexpotta;bnfy?. .. 6nt�feav ng U S:!.
<br /> 17 TransporterAclawWledgmentofNece1ptof iatenais
<br /> T�anspor�ter nntedl3ypadName .t v Slgnaturg, Month Day ,fear
<br /> Transportet2Printedlfypedtdame Signature, Month Day Year:
<br /> 18,Discrepancy.
<br /> 1m.D3 grepancy indication Space,',: f—7
<br /> :`Gk entity.'...•. LJ type, lJ Residue•' El Part(al Rejection �FuIl Rejection.
<br /> �Aamfest Reference Nbmber:,
<br /> �, FacElity'sPhone. ' •
<br /> LU 18c:Signature&Alternate Facility or Generator)' Month Day Year
<br /> 19 Hazardous Waste Kapott Management Method Codes(Le„modes•forfiaYardoa's'wastetfeahnent disposal,and recydingsysterps)>;. ..
<br /> 2b:t?eslgnatetl Facilltq Overeat of Operator;Cehifioattoh ofreCeipt'of hatardous fneterials covereti by the marrifesi excep# s,ridad rPitem i8a ,;
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<br /> EPA Form 8.700-22 ev.3 0 j Previous edrttons are Desolate, DESIGNATED FA Uri .TO.�����A,q•®R
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