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<br /> ' Form ApproVect:OMB.No,2450-004
<br /> 1 GeneratoriD umber r 2 Page 4 '3 EmergenoyResponsePhone• 4'ManifastT ctong umbe�k
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<br /> WASTE MANIFEST. e�"d. ' ^ ..:r: " jU .
<br /> 5.G.Bne ator s N me n Malkin. ddress Generator's:Site Address(if different than inalifng address).
<br /> GeneraloYs Pfid et r "
<br /> 6 Trans rter 1 Company Name U.SEPA ID Number
<br /> 77ransporti2 anyNarrte » U.S EPA IDNUm�
<br /> a�DeFac�ityNameandSitetAddrass .r
<br /> U.S EPA iD Number.
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<br /> Paelity
<br /> 9b U S DbTdascriptio'n Qncduding Piope?S Aping Namq,'Hazard Odss,4D Number, 10:Containers. til.Total 12.Unif• 13.Waste Codes
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<br /> W'S©BFEE2Y3 „i EtPS�i�TttSN}i peebpdeClgta Ufatttie contents oithls consignment areiuily antl accur8#siy.deseriired abbvs.by the ptbper:shippY�y name;drd ere Np§sdied packeged
<br /> mB K d;ehc�)abetedfpfae riled,a taare° tl;tespectsin propatcondit on forlrarisportaccoiifibg fo 60111.file.intematioheland nat on8l governmentei ragUiationsexporfshipment andl'aroihePrimary
<br /> xporterFl rsnUy ihaelhe �,fs�Slth�s cohslgnment Cdiiform#o.the;tetins ot. ea ttached EPAAcknowledgmeni nt Consent. •,
<br /> I cerlt�y tha6Uievt ate mimlz oil s#alemg it Iden6tiectlri p0 GfR 26?27(a)'�iFl am a Targe quan4iygeperator)or(bj Qf1,am a!9 ntali q fame generator)is Prue
<br /> QeeratorslOffero�s PnhtedllyGed:Nam(e �/ Signature,„» } oath Day Year
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<br /> Port Qf enUyleiiit'
<br /> s' .Trans ersi�r�ature(for expods only,)
<br /> Date leaving U.S.:
<br /> IT-Tea hspdrte(Rcio�btMe�gmetitb4dieCs1ptofRRatenal`s
<br /> a,7ranspbrier 1'PhntedfTypad Name,a .V S t6 — Month DaY. Year',
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<br /> zTranspo#er 2 Panted Type N e Si9netttre M (b ay Year
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<br /> .�: 18:Olscteparroy :,; :•. .. ?" .,r.•. r--i. :'. ..... . .,
<br /> 18a,pisCtepancy tiidica6on Space .quefjtlty fyp'e .: QRes dtia 0 Pertlaf�Reieoh'on t_ FUtI ReJeeGon '
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<br /> .., Manifest Reference Number
<br /> 8b AlternatePacility(or Generators U.S.EPAID Number
<br /> • Fac{itys Phone , ,,; Month Day Year
<br /> 18c.Srgnature of Alternate Paciiity(or Generator)
<br /> n.•99 iiazardbus Vt'aSte Report MarragementMotnbd Codes(t e.,codes forhaza�dous d+aste treatment,dispasai arld reoj cling systems)
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<br /> 20.Designated:Fadilty Owner or Opera#or Cerbticatton of receipt of hazardous mateiial's covered by the manrfest;dzcept as notedln itam.18a
<br /> Pnnted/Typed Name
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<br /> i, EPA Form 8704-22(E7ev,.3 05)7PreviousedtEiotis are obsoli(e �) r . DESIGNATED, ACILIT'(`�°O.GENERATE&&
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