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I <br /> i <br /> Form Approved.OMB No.2050-DO39 <br /> Please print or type. <br /> 1.Generator IQ Number 2.Page 1 of 3.Emergency <br /> Phone 4.Manifest 7racking Number �� <br /> UNIFORM HAZRRCIOIfS n 0` d n� 021985,589 <br /> WASTE MANIFEST t, :r ri.' <br /> 5.Generator,-,Name and Mailing Address Generator`s Site Address(If ditlerenl Than mailing address) <br /> Siiq",�,,,,1-i 6rr_�l USA e;�o�a:�aa �tetra S,A; ,w SA :clot f � <br /> ��. .; 'tom?'�,a��u�<I�s�Vit.y.� <br /> Generator's Phona: ` 0 4 <br /> U.S.EPA tD Number <br /> 8.Transporter 1 Company Name 7 g y g <br /> , <br /> U.S.EPA It]Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> fulml T S0V 1" <br /> 1 w mrii-In- <br /> Facility's Phone: <br /> 9a. Bb.U.S.DoT Description(including Proper Shipping Name,Hazard Class,10 Number, Y0,Containers 14.Total 12.Unit tity Wt.rVol. 13 Waste Codes <br /> HM and Packing Group(if any)} No-. Type Quan <br /> 1. j3ssi f' ��t d ye r wG} { 0b:s`id1W t' - <br /> I <br /> LU 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information € ��,fit�z�y�� hit, :',_ 2 " '' 3 <br /> 15. G£NERATOR'SIOFFEROR'S CERTIFICATION, I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping flame,and are classified,packaged, <br /> marked and labeledtp#acarded,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 /> t certify that the waste minimization statement identified in 40 CFR 262.27(x}(if I am a large quantity generator)or(b)(0am a small quantity generator)is true. <br /> Signature- Monlh clay Year <br /> £e[IT 3Kcz'sfOf4eror s Prince ffyped Name <br /> 16.International Shipments importlo U.S. ❑Export from U.S. Pott of entrylexie <br /> Transporter signature(for exports only}: <br /> Data leaving U.&: <br /> W 17.TransportorAcknowtedgmentciRe"iptafMatadals re <br /> Slgnatur A9anth Day Year <br /> Tn#nsporter 1 PrintedfTyped Name <br /> C]63 l. wt_. ; / <br /> t .. �} <br /> en <br /> Transporter 2.Frit, ciffyped Name <br /> Signature Month Oxy Year <br /> 18.Discrepancy <br /> Type Residue ElPartial Rejection Full Rejection <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity <br /> Manifest Reference Number_ <br /> U.S.EPA IQ Number <br /> F� 18b.Alternate Facility(or Generator) <br /> :5 <br /> G3 <br /> u Facility's Phone: Month Oxy Year <br /> 18c.Signature of Alternate Facility(or Generator) <br /> LUz <br /> 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste Iraatme11 n 11 t disposal,and recycling systems) <br /> UJ 1 2. 3. 4. <br /> n <br /> 20.Designaled Facility Owner or operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 183 htong Day Year <br /> Printedtiyped Name <br /> Signature <br /> EPGENERATOR'S INITIAL A Form 8700.22(Rev.12-17) Previous editions are obsolete. <br />