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Please print or type.(Form designed for use on ellte(12-V9ch)typewrifer Farm Approved.OMB Na.2050-0039 <br /> UNIFORM HAZARDOUS <br /> 1,Generator ID Number " 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number _ <br /> WASTE MANIFEST G;�k 0 6 01 E��A 3.0 � S, s f���)�3[�., H c�€� ��.� i s;� ��� �� � 7 JJ <br /> 5.Gneralas ameandLlaikngAddress Generator's Site Address(it diftorentthan mailing address) <br /> Ilk <br /> `J <br /> I <br /> 3 <br /> k'?�tii'' �' i {�F k 4E, <br /> L ! ,i 104 E, <br /> ll i s €rr , LOW rapt 95240 <br /> Generatofs Phone: ``'" <br /> 6_Transporter I Company Name � � U.S.EPA ID Number �����` � <br /> g s; O[ Vra;T€MA.AMr-M-M).SI-(:1 f31 s?... € ;a E <br /> ;: <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> WOMMUIDE <br /> E1G101j1'F--,t1Y 311Y1_1 rMi INC, <br /> 8,Designated Facility Name and$IteAddress U.S.EPA ID Number <br /> YES <br /> �`{a{ka. RE-, /��``''yy FF ++##[[ <br /> �/U AA *24%41-28, FM rr:`�Te 1' f�G -_S ASS.S . <br /> Facfll s Phone; <br /> 9a. 9b,U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 14,Containers 11,Total 12.Unit 13,Waste Codes <br /> HM 'and Packing Group(if any)) No. Type Quantity Wt.Noi. r <br /> ;..OUta 8 MAKE LATHE.-SRAVtNGS <br /> LU <br /> 3. -. <br /> 14:Spedal Handling lnstruclions andAddillonal Information <br /> s 91xFWsF.1*,WtItN:A6f .131 FE3:T REX1-M1,424-0 TERMINAL CM:S HS ., OrI€f:.0 <br /> K��. <br /> 15, GENERATORWOFFFROWS CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classftied,packaged, <br /> marked and labeledlpfacarded,and are in all respects In proper condldon for transport according to applicable International and national govemmenial regulations.If export shipment and I am the Primary <br /> Exporter,I cadify that the contents of this eonsignmentoenfomr to the terms of the attached EPAAcknowledgment of Consent. <br /> t certily that the waste minimization staloment identltied in 40 CFR 262.27(a)(If I am a large quanlitygenerator)of(b)(if I am a small quantitygenerator)is true. <br /> Genom(ofsl0ffaroes PdnledfTyped Name signaluro _ Month_ Day Year <br /> �J 16.Intemaifonal Shipments <br /> T ❑Import to U.S. 0a from U.S. Port of entryloxit: <br /> Transporter slgnatufe(for exports only): Date leaving U.S.: <br /> W 17.TranspoderAcknowledgmentof Receipt of Materials ? ' <br /> Transporter 1 PrintepgdffypedName 1 �j Slgnaluree Month Day Year <br /> T€agsponer 2 Pdnted(fyped Name Signature a Day Yea r t <br /> 18.Discrepancy <br /> 18a.Discrepancy,l«dicailon Space Quantity w Typo Residue ❑Partial ReJaotlon ❑Full Refection <br /> Manifest Reference Number: <br /> 18b.Allemate Facility(orGenerator) U.S,EPA ID Number <br /> U • <br /> Facility's Phone: f <br /> Lu <br /> 18c.SlgnaiureofAllemaleFaciiity(orDeneraiar) Month Day Year s <br /> l <br /> a <br /> 19.Hazardous Waste Report Management Method Codes(I.e.,codes lot hazardous waste treatment,disposal,and ruoycIN systems) <br /> LLI 1, 2. 3. 4. i <br /> 20.Designated Facility Owner or.Opemlor.Cert kallon of receipt of hazardous materials covered by the manifest excopt as noted in Item 188 ` <br /> t <br /> PrintedfFyped NameSignature Month Day Year <br /> t 1 F <br /> EPA Form 8704-22(Rev.3-05) Previous edtllons are obsolete, 4 , 1 DbMCM,t>TED FAC)L MY TO G ENE $1 Q <br />